No Relationship Between Strength and Power Scores and Anterior Cruciate Ligament Return to Sport After Injury Scale 9 Months After Anterior Cruciate Ligament Reconstruction

Assessing the Relationship of Psychological Sport Readiness, Single-leg Vertical Jump, and Non-Sagittal Single-Leg Hops to Quadriceps Strength After Anterior Cruciate Ligament Reconstruction

Background

Limitations exist with current ACLR functional testing assessments that may be mitigated by including single-leg multi-directional testing.

Hypothesis/Purpose

To compare Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI) scores, limb symmetry index (LSI) of the single-leg vertical jump (SLVJ), single-leg medial rotation hop (SLMRH), single-leg lateral hop (SLLH), and isokinetic quadriceps strength between participants with an ACLR and healthy controls and assess predictors of quadriceps strength asymmetry. It was hypothesized that ACL-RSI scores and LSIs for all tests would differ between ACLR and healthy control groups and within the ACLR group a strong correlation would exist between all outcome measures and quadriceps strength.

Study Design

Cross-Sectional Study.

Methods

Twenty-six participants with an ACLR (median 13 months after surgery) and twenty-six matched healthy controls were recruited to participate in this study. Performance was assessed via SLVJ, SLMRH, SLLH, and isokinetic quadriceps strength. Between-group comparisons were made with independent t-tests and Mann-Whitney U test. Within the ACLR group, bivariate correlation and multivariate regression analysis were performed to assess the relationship between the outcome measures and quadriceps strength asymmetry.

Results

Significant between-limb differences were only identified in the ACLR group (p< 0.05): SLVJ LSI: 88.5%, SLMRH LSI: 93.6%, SLLH LSI: 92.7%, quadriceps strength LSI 80.9% - 83.9%, which were significantly lower (p <0.05) than the healthy control group. Within the ACLR group, a moderate-strong significant (p < 0.05) correlations existed with quadriceps strength and SLVJ (r=0.44-0.65), SLMRH (r =0.43-0.83), and SLLH (r=0.54-0.63); while ACL-RSI had a weak non-significant (p > 0.05) correlation with quadriceps strength (r= 0.12-0.30).

Conclusion

Single-leg multidirectional test LSIs were less in ACLR participants than matched healthy controls and all were directly related to quadriceps strength. Psychological readiness to return to sport was not related to quadriceps strength.

An 8-week physiotherapist-led return to sport group program after anterior cruciate ligament reconstruction improves measures of physical and psychological function: A case series

BACKGROUND

Low return to competitive sport, high reinjury rates and long-term functional impairment of anterior cruciate ligament reconstruction (ACLR) present significant challenges for patients. A program that facilitates a safe return to sport (RTS) following ACLR could potentially improve outcomes.

STUDY DESIGN

Case Series.

METHODS

Sixty participants (median 20-years-old (13-36), 43 males, 18 females, median 7.5 months (4-25) post-ACLR) completed an eight-week exercise program. A battery of physical tests and patient-reported outcome measures were assessed pre and post-program. The number of participants passing RTS criteria was evaluated, and RTS rates were determined. The correlation between the ACL-RSI and measures of physical function was explored.

RESULTS

Improvements in all isometric strength, hop tests, running T-test, and patient reported outcome measures were seen post-program. Five (8%) participants successfully passed all RTS criteria and eighty-five percent of participants returned to their previous level of sport. The ACL-RSI and the IKDC showed correlation across all time points (pre rs = 0.49; post rs = 0.40; change r = 0.40).

CONCLUSIONS

Our study demonstrated improvements in all RTS criteria tests upon completing the 8-week rehabilitation program; however, few participants (8%) passed all RTS criteria. Psychological readiness is more closely related to patient-reported function than functional tests.

Comparison of Contralateral ACL Rupture Versus ACL Graft Rupture in Australian Netballers After ACL Reconstruction

Background

Netball is a popular sport worldwide, particularly for women. However, its nature puts players at high risk for anterior cruciate ligament (ACL) injury.

Purpose

To determine (1) the prevalence of ACL graft rupture and contralateral ACL (CACL) rupture in Australian female netballers after ACL reconstruction (ACLR) and (2) the rate of return to sports (RTS) and psychological readiness.

Study Design

Cohort study; Level of evidence, 3.

Methods

A patient database identified 332 consecutive female netball players who underwent ACLR with hamstring tendon autografts performed by 2 surgeons between 2007 and 2015. Patients were retrospectively surveyed at a minimum of 7 years postoperatively-including details of a second ACL injury to either knee, RTS, and psychological readiness per the ACL-Return to Sport After Injury (ACL-RSI) score. Multivariate regression assessed the association between selected variables and repeat ACL injury.

Results

A total of 267 patients (80%) were included with a mean follow-up of 8.4 years (range, 7-15 years). ACL graft rupture and CACL rupture occurred in 11 (4%) and 27 (10%) patients, respectively, at 7 years postoperatively. The ACL graft had a survival rate of 99%, 97%, 97%, and 96% at 1, 2, 5, and 7 years after surgery, respectively. The native CACL had a survival rate of 100%, 99%, 94%, and 90% at 1, 2, 5, and 7 years, respectively. Adolescents had a 4.5 times greater hazard for ACL graft rupture (95% CI, 1.4-14.6; P = .014) and a 2.5 times greater hazard for CACL rupture (95% CI, 1.2-5.5; P = .021) compared with adults. CACL injury was also associated with a return to level 1-including jumping, hard pivoting, and cutting-sports (hazard ratio, 10.3 [95% CI, 1.4-77.1]; P = .023). Most (62%) participants returned to netball, with those with higher ACL-RSI scores more likely to RTS.

Conclusion

The prevalence of repeat ACL injury was higher in the contralateral knee (10%) than the ACL-reconstructed knee (4%) at 7 years postoperatively. ACLR was a suitable option for female netballers who sustained an ACL rupture with low long-term rates of graft rupture. Repeat ACL injuries to either knee were more common in adolescents and those who returned to cutting and pivoting sports.

Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis

BACKGROUND

Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary.

OBJECTIVE

To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores.

METHODS

Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach).

RESULTS

A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%).

CONCLUSION

Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions.

REGISTRATION

Open Science Framework (OSF), https://osf.io/2tezs/ .

Knee Confidence, Fear of Movement, and Psychological Readiness for Sport in Individuals With Knee Conditions: A Systematic Review and Meta-analysis

OBJECTIVES: To (1) compare activity-related psychological factors between individuals with and without knee conditions, and (2) assess associations between these factors and objective measures of function in individuals with knee conditions. DESIGN: A priori registered systematic review with meta-analysis. LITERATURE SEARCH: MEDLINE-Ovid, Embase-Ovid, Scopus-Elsevier, CINAHL-EBSCO, SPORTDiscus-EBSCO, and Cochrane Library were searched to May 27, 2022. STUDY SELECTION CRITERIA: We included peer-reviewed primary data studies (observational and experimental) of human participants with and without knee conditions reporting knee confidence, fear of movement/avoidance beliefs, and/or psychological readiness to return to sport (RTS) or reporting correlations between these factors and objective measures of function in knee conditions. DATA SYNTHESIS: Where possible, data were pooled by knee conditions, otherwise performed narrative syntheses. The Downs and Black checklist assessed the methodological quality of the included studies. RESULTS: Forty studies (3546 participants with knee conditions; 616 participants without knee conditions) were included. There was very low-certainty evidence of higher fear of movement in individuals with knee osteoarthritis (standardized mean difference [SMD], 0.46; 95% confidence interval [CI]: 0.41, 0.52), but not in individuals with patellofemoral pain (SMD, 0.66; 95% CI: -7.98, 9.29) when compared with those without knee conditions. There was very low-certainty evidence of no differences in psychological readiness to RTS after anterior cruciate ligament reconstruction (SMD, -1.14; 95% CI: -2.97, 0.70) compared to no knee condition, and negligible to weak positive correlations between psychological readiness to RTS and objective measures of function. CONCLUSION: There was very low-certainty evidence of higher fear of movement in individuals with knee osteoarthritis compared to those without, and very low-certainty evidence of no correlations between these factors and objective measures of function following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2024;54(4):1-14. Epub 29 January 2024. doi:10.2519/jospt.2024.12070.

The Influence of Strength and Sport Exposure on Psychological Readiness After ACL Reconstruction

BACKGROUND

Among young athletes returning to sport after anterior cruciate ligament reconstruction (ACLR), the extent to which psychological readiness is influenced by factors beyond the psychological domain is largely unknown.

HYPOTHESIS

Young athletes with recent sport exposure and higher quadriceps strength will demonstrate higher psychological readiness within 8 weeks of medical clearance to return to sport (RTS) after ACLR.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 38 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. All participants completed isometric knee extension strength testing, in addition to the ACL Return to Sport after Injury (ACL-RSI) questionnaire. Athletes who participated in sport between time of medical clearance to RTS and date of study enrollment were categorized as SPORT-YES. Those who had not yet participated in sports were categorized as SPORT-NO. Multiple linear regression analyses were used to determine differences in ACL-RSI scores based on quadriceps strength and sport exposure status, while adjusting for age and sex.

RESULTS

Of the 38 participants, 20 (52.6%) were categorized as SPORT-YES. The regression model estimating overall ACL-RSI score (P < 0.01, adjusted R2 = 0.389) included significant independent contributions from age, sex, and sport exposure variables (age: P = 0.01, β [95% CI] = -2.01 [-3.54, -0.48]; sex (male): P = 0.02, β [95% CI] = 12.50 [2.36, 22.64]; strength: P = 0.51, β [95% CI] = -2.47 [-10.07,5.13]; sport exposure: P < 0.01, β [95% CI] = 12.89 [3.58, 22.19]).

CONCLUSION

In partial accordance with our hypothesis, recent sport exposure was significantly associated with higher ACL-RSI scores among young athletes in the weeks after medical clearance to RTS after ACLR, while quadriceps strength was not.

CLINICAL RELEVANCE

Future prospective work is needed to determine the existence and direction of causal relationships between exposure to sport environment and psychological readiness among young athletes after ACLR.

Acute and Chronic Effects of Blood Flow Restriction Training in Physically Active Patients With Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Muscle atrophy and loss of knee function are common findings after anterior cruciate ligament (ACL) reconstruction. Rehabilitation through blood flow restriction (BFR) has gained clinical relevance when combined with low loads to improve these disorders in recent years.

OBJECTIVE

To evaluate the rehabilitation effectiveness of ACL reconstruction with the use of BFR on pain, functionality, strength, and muscle mass in physically active people.

DATA SOURCES

A search of PubMed, Web of Science, and MEDLINE was performed on March 31, 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

STUDY SELECTION

Randomized clinical trials with active adults who underwent ACL surgery were included. They had to compare conventional treatments with the use of BFR, reporting values of pain, functionality, strength, or cross-sectional area (CSA). Articles whose participants presented concomitant injuries and whose intervention combined the use of BFR with treatments other than resistance training were excluded.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 2.

DATA EXTRACTION

Study design, population, cuff pressure, and main outcomes including strength, quadriceps CSA, pain, and functionality.

RESULTS

Six studies out of a total of 389 were included (152 participants; 90 men and 62 women). These included studies showed no differences on CSA or strength when comparing BFR training with high loads exercise. BFR has demonstrated improvements in knee functionality and pain compared with other interventions such as immobilization or high loads training.

CONCLUSION

The use of low loads combined with BFR improves pain, strength, functionality, and CSA. In addition, knee pain reduction and functionality are greater with BFR compared with the use of high loads or immobilization.

The Role of Strength-Related Factors on Psychological Readiness for Return to Sport Following Anterior Cruciate Ligament (ACL) Reconstruction

Psychological readiness following anterior cruciate ligament reconstruction (ACLR) correlates with different return to sport outcomes. However, the relationship between strength and power and psychological readiness remains unexplored. The aim of this study was to investigate the relationship between anterior cruciate ligament return to sport after injury (ACL-RSI) scores and various hamstrings and quadriceps strength and power variables. Twelve participants (20.7 ± 2.5 years old; 174.2 ± 7.5 cm; 70.2 ± 8.5 kg; 18.2 ± 8.3% of body fat) who had an ACLR nine months or more before the study completed the ACL-RSI questionnaire and isokinetic strength testing of the hamstrings and quadriceps (60°·s-1 and 180°·s-1). Based on ACL-RSI scores, they were divided into "cases" and "controls", deemed not psychologically ready and psychologically ready to return to previous sport performance (PILOS), respectively. The main findings are that quadriceps' and hamstrings' rate of torque development (RTD) and time since surgery were determinants of psychological readiness following ACLR. Furthermore, compared to controls, cases showed significantly lower quadriceps torque at angles close to full knee extension (40 deg and 30 deg from extension). They also showed lower RTD than controls, but no difference in peak torque. These results suggest that physiotherapists should facilitate athletes' return to sport (RTS) by focusing on the restoration of RTD and strength at angles close to full knee extension.

Gender does not impact clinical outcomes following SLAP repair

Background

The purpose of the current study was to investigate whether pain, function, satisfaction, return to play (RTP), or psychological readiness to RTP differ between sexes post-operatively following SLAP repair.

Methods

A retrospective review of patients who underwent arthroscopic repair of a SLAP tear was performed. The American Shoulder & Elbow Surgeons (ASES) score, Visual Analogue Scale (VAS), Subjective Shoulder Value (SSV), patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. Clinical outcomes were compared between male and female patients.

Results

Our study included 169 patients treated with SLAP repair, 133 of them male (78.7%) and 36 of them female (21.3%), with an average age of 32.3 ± 8.3 and 33.4 ± 6.8 respectively. The mean follow-up duration was 5.8 years. At final follow up, there was no difference between treatment groups in any of the functional outcome measures assessed (p > 0.05).

Conclusion

There is no difference in clinical outcomes, function, satisfaction, or revision procedures in mid- to long-term follow-up after SLAP repair between male and female patients. This data is useful in the preoperative counselling of patients undergoing arthroscopic management of symptomatic superior labral pathology.

Level of evidence

III.

Return-to-sport criteria after isolated meniscus suture: Scoping review of the literature

BACKGROUND

Follow-up care including rehabilitation therapy after isolated meniscal repair remains to be standardized. Thus, no standard criteria are available for the return-to-running (RTR) or return-to-sport (RTS). The objective of this study was to identify criteria for RTR and RTS after isolated meniscal repair, based on a review of the literature.

HYPOTHESIS

Return-to-sport criteria after isolated meniscal repair have been published.

METHODS

We performed a scoping review of the literature using the methodology developed by Arksey and O'Malley. The terms "menisc*" and "repair" and "return-to-sport" or "return to play" or "return to run" or "rehabilitation" were used to search the PubMed database on 1st March 2021. All relevant studies were included. All RTR and RTS criteria were identified, analyzed, and classified.

RESULTS

We included 20 studies. Mean RTR and RTS times were 12.9 and 20 weeks, respectively. Clinical, strength, and performance criteria were identified. The clinical criteria included full range-of-motion recovery with no pain, quadriceps wasting, or joint effusion. Strength criteria were a quadriceps and hamstring deficit, no greater than 30% and 15% for RTR and RTS, respectively, compared to the normal side. Performance criteria were successful completion of proprioception, balance, and neuromuscular tests. RTS rates ranged from 80.4% to 100%.

CONCLUSION

Patients must meet clinical, strength, and performance criteria before resuming running and sports. The level of evidence is low, due to the heterogeneity and generally arbitrary choice of criteria. Further large-scale studies are therefore needed to validate and standardize RTR and RTS criteria.

LEVEL OF EVIDENCE

IV.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

BACKGROUND

Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes.

PURPOSE

To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS.

RESULTS

Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245).

CONCLUSION

A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

The Association of Physical Competence With Psychological Response Among Young Athletes at Time of Return to Sport After ACL Reconstruction

BACKGROUND

The traditional index of return-to-sport (RTS) readiness after anterior cruciate ligament reconstruction (ACLR) is the achievement of physical competence criteria. Emerging research indicates that psychological response and self-perceptions of physical competence may be critical mechanisms for successful RTS among young athletes.

HYPOTHESIS

Young athletes with higher actual physical competence (APC) and perceived physical competence (PPC) will demonstrate a more positive psychological response at the time of RTS after ACLR.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 41 young athletes after primary ACLR completed testing within 8 weeks of medical clearance to RTS. APC was measured with isokinetic knee extension strength, single-limb crossover hop for distance, and the Knee injury and Osteoarthritis Outcome Score. PPC was measured with the Athletic Competence subscale of the Self-Perception Profile. Criteria for APC and PPC were based on established age- and activity-relevant cutoff scores. Different constructs of psychological response were assessed with the adapted Sport Motivation Scale, Brief Resilience Scale, and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) total and subscale scores (Emotions, Confidence, and Risk Appraisal). Multiple linear regression analyses were used to determine differences in measures of psychological response based on achievement of APC and PPC, while adjusting for age and sex.

RESULTS

Of the 41 participants, 10 (24.4%) met all criteria for APC and 22 (53.7%) met the PPC criteria. The regression models estimating the ACL-RSI score (P < .001; adjusted R2 = 0.331), ACL-RSI Emotions score (P < .001; adjusted R2 = 0.427), and ACL-RSI Risk Appraisal score (P = .013; adjusted R2 = 0.212) were statistically significant. Although APC was not associated with any measure of psychological response, meeting PPC criteria, younger age, and male sex were found to be associated with a more positive psychological readiness to RTS, but not with motivation or resilience.

CONCLUSION

Meeting PPC criteria was associated with higher psychological readiness to RTS among young athletes after ACLR, while meeting APC criteria was not associated with any construct of psychological response.

Performance in field-tests and dynamic knee valgus in soccer players psychologically ready and not ready to return to sports after ACL reconstruction

BACKGROUND

The objective was to compare the performance in field tests, dynamic knee valgus, knee function, and kinesiophobia of soccer players who were psychologically ready and not ready to return to unrestricted training or competitions after ACL reconstruction.

METHODS

Thirty-five male soccer players who had undergone primary ACL reconstruction at least 6 months were divided based on the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) questionnaire score into ready (≥60) and not-ready (<60) groups. The modified Illinois change of direction test (MICODT) and reactive agility test (RAT) were used to impose the demand for directional change and reactive decision-making. We assessed the frontal plane knee projection angle (FPKPA) during a single-leg squat and distance in crossover hop test (CHD). In addition, we assessed kinesiophobia through the shortened version of the Tampa Scale of Kinesiophobia (TSK-11) and knee function using the International Knee Documentation Committee Subjective Knee Form (IKDC). Independent t-tests were used to compare the groups.

RESULTS

The not-ready group had lower performance on the MICODT (effect size (ES) = -1.2; p < 0.001) and RAT (ES = -1.1; p = 0.004) tests and higher FPKPA (ES = 1.5; p < 0.001). In addition, they presented lower IKDC (ES = 3.1; p < 0.001) and higher TSK-11 (ES = -3.3; p < 0.001) scores.

CONCLUSIONS

Physical and psychological deficits may persist in some individuals after rehabilitation. On-field tests and dynamic knee alignment evaluation should be included in the athlete evaluation before the decision-making about clearance to sports participation, especially in athletes who perceive themselves as psychologically not ready.

Subjective knee apprehension is not associated to physical parameters 6–12 months after anterior cruciate ligament reconstruction

Purpose

Anterior cruciate ligament (ACL) rupture is a common injury and psychological parameters measured at 6–8 months are said to be almost more predictive for return to sport (RTS) than physiological. Purpose was 1) to evaluate the correlation between knee apprehension using ACL-RSI and physical factors after ACL reconstruction (ACLR), 2) to assess the correlation between ACL-RSI and patient parameters (age, pivot-sport, BMI), and 3) to evaluate ACL-RSI over time.

Methods

Patients with ACLR with or without meniscal repair between 2013 and 2020 were retrospectively analyzed. Including criteria were RTS testing battery, assessed at least 6 months after surgery, including physical parameters (strength, triple hop test, side hop test, and bilateral knee stability) and psychological parameters (ACL-RSI). 5 subgroups were analyzed to assessed factors such as age, BMI, pivot sport, time interval between two RTS testing battery.

Results

Three hundred three patients (212 male, 91 female) presenting ACLR were included. Mean age at surgery was 27 (± 8) years. 258 patients practiced pivot-sport activity and 45 non-pivot-sport activity. The mean interval between ACL rupture and surgery was 6.5 (± 4.5) months. RTS testing battery were performed at 8 (± 7) months after ACLR.

Mean ACL-RSI was 58 (± 28). 1) ACL-RSI was not influenced by muscle strength, coordination and stability of the knee. 2) ACL-RSI was significantly better in lower BMI and non-pivot-sport activities. No correlation was found between graft type, age, sex, and ACL-RSI assessment. 3) For patients who performed two RTS testing battery at 8 and 12 months, ACL-RSI did not significantly increase over time (56 to 64 points, p = 0.22) in spite of significant increased quadriceps (127 to 151 Nm/kg, p = 0.005) and hamstring (93 to 105 Nm/kg, p = 0.05) strength.

Conclusions

Psychological readiness before RTS, measured upon ACL-RSI does not correlate with any physical parameter at 8–12 months postoperatively. Although quadriceps and hamstring strength increased significantly over time, ACL-RSI does not and must therefore be routinely assessed.

'Such a massive part of rehab is between the ears'; barriers to and facilitators of anterior cruciate ligament reconstruction rehabilitation: a qualitative focus group analysis

Background

Current evidence demonstrates that few patients complete anterior cruciate ligament reconstruction rehabilitation according to evidence-based guidelines. It is important to investigate the viewpoints of our patients to identify patient-reported barriers and facilitators of anterior cruciate ligament reconstruction rehabilitation. Qualitative analysis can provide insight into potential methods for improving the delivery of rehabilitation services.

Methods

In this qualitative study, utilising a social constructionism orientation, viewed through the social phenomenological lens, three focus groups were conducted with individuals 1–20 years post anterior cruciate ligament reconstruction (n = 20, 9 males, 11 females, mean 6.5 years post-surgery, 19–51 years old). Utilising a semi-structured interview guide, participants were asked about their experiences during anterior cruciate ligament reconstruction rehabilitation. Focus groups were recorded, transcribed, and coded using an inductive semantic thematic analysis methodology.

Results

Five organising themes were identified (consisting of 19 sub-themes) to provide a framework to present the data: psychological, physiological, rehabilitation service, rehabilitation characteristics, and interaction with others. Each theme details aspects of rehabilitation, such as exercise delivery, informational support, frequency, and duration of care, kinesiophobia, weight management and interactions with teams and coaches, which present barriers or facilitators for patients to adhere to and participate in rehabilitation. Example quotes are provided for each theme to provide context and the patient’s voice.

Conclusions

This qualitative investigation identified key aspects of a patient's rehabilitation in which they encounter a variety of barriers and facilitators of ACL reconstruction rehabilitation. These aspects, such as the rehabilitation characteristics, service delivery, psychological and physiological factors, and interactions with others, were consistently identified by this cohort as factors which affected their rehabilitation. The themes may provide targets for clinicians to improve rehabilitation and deliver patient-centred care. However, the themes must be evaluated in future trials to assess whether interventions to remove barriers or enhance facilitators improves subsequent outcomes such as return to sport and re-injury rates.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-022-00499-x.

What tests should be used to assess functional performance in youth and young adults following anterior cruciate ligament or meniscal injury? A systematic review of measurement properties for the OPTIKNEE consensus

OBJECTIVES

To critically appraise and summarise measurement properties of functional performance tests in individuals following anterior cruciate ligament (ACL) or meniscal injury.

DESIGN

Systematic review.

DATA SOURCES

Systematic searches were performed in Medline (Ovid), Embase (Ovid), CINAHL (EBSCO) and SPORTSDiscus (EBSCO) on 7 July 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies evaluating at least one measurement property of a functional performance test including individuals following an ACL tear or meniscal injury with a mean injury age of ≤30 years. The COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist was used to assess methodological quality. A modified Grading of Recommendations Assessment, Development and Evaluation assessed evidence quality.

RESULTS

Thirty studies evaluating 26 functional performance tests following ACL injury were included. No studies were found in individuals with an isolated meniscal injury. Included studies evaluated reliability (n=5), measurement error (n=3), construct validity (n=26), structural validity (n=1) and responsiveness (n=1). The Single Leg Hop and Crossover Hop tests showed sufficient intrarater reliability (high and moderate quality evidence, respectively), construct validity (low-quality and moderate-quality evidence, respectively) and responsiveness (low-quality evidence).

CONCLUSION

Frequently used functional performance tests for individuals with ACL or meniscal injury lack evidence supporting their measurement properties. The Single Leg Hop and Crossover Hop are currently the most promising tests following ACL injury. High-quality studies are required to facilitate stronger recommendations of performance-based outcomes following ACL or meniscal injury.

Cross-sectional study on relationships between physical function and psychological readiness to return to sport after anterior cruciate ligament reconstruction

BACKGROUND

Information about specific factors of physical function that contribute to psychological readiness is needed to plan rehabilitation for a return to sports. The purpose of this study was to identify specific physical functions related to the psychological readiness of patients aiming to return to sports 6 months after reconstruction. We hypothesized that the knee strength is a factor related to the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) cutoff score for a return to sports.

METHODS

This was a cross-sectional study. Fifty-four patients who had undergone primary reconstruction using hamstring tendon participated in this study. Psychological readiness was measured using the ACL-RSI in patients at 6 months after reconstruction. To identify specific physical functions related to the ACL-RSI score, participants were divided into groups with ACL-RSI scores of ≥ 60 or < 60. Non-paired t-tests or the Mann-Whitney test were performed to analyze group differences in objective variables in physical function: (1) knee strength in both legs; (2) leg anterior reach distance on both sides; and (3) single-leg hop (SLH) distances in three directions for both legs.

RESULTS

Significant differences between groups were identified in knee flexion strength (60°/s) for the uninvolved limb, hamstring-to-quadriceps ratio (60°/s) for the uninvolved limb, knee flexion strength (180°/s) for the involved limb, limb symmetry index (LSI) of leg anterior reach distance, the ratio of the distance to the height of the patient and LSI of SLH distances in lateral and medial directions.

CONCLUSION

This study revealed that at 6 months after reconstruction, increased knee flexion strength (ratio of peak torque measured to body mass of the patient), hamstring-to-quadriceps ratio, leg anterior reach distance LSI, and lateral and medial SLH appear important to exceed the ACL-RSI cutoff for a return to sports. The present results may be useful for planning post-operative rehabilitation for long-term return to sports after reconstruction.

Association Between Meeting Return-to-Sport Criteria and Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction

Background:

The relationship between meeting return-to-sport criteria and psychological readiness after anterior cruciate ligament (ACL) reconstruction is unknown.

Purposes:

To examine (1) whether patients who met 1 of the criteria for return to sport had higher psychological readiness than those who did not meet any of the criteria and (2) if those who met more criteria had higher psychological readiness.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

This study included 144 patients who underwent unilateral ACL reconstruction. All patients had regularly participated in some sport activities before an ACL rupture. At 12 months postoperatively, each patient completed 3 knee function tests (isokinetic quadriceps strength, isokinetic hamstring strength, and single-leg hop distance) and 2 self-reported measures (International Knee Documentation Committee [IKDC] 2000 subjective form and ACL–Return to Sport after Injury [ACL-RSI] scale); the ACL-RSI scale was used to measure psychological readiness to return to sport. The 4 criteria for return to sport were a limb symmetry index (LSI) ≥90% for each of the 3 function tests in addition to an IKDC score ≥90. Multivariate regression analysis was used to determine the association between meeting the individual criteria and the ACL-RSI score. In addition, the patients were divided into 5 groups according to the number of criteria met, and the Kruskal-Wallis and Steel-Dwass tests were used to compare the ACL-RSI scores among the groups.

Results:

Overall, 23 patients (16.0%) met none of the criteria for return to sport, 27 (18.7%) met 1 of the criteria, 34 (23.6%) met 2 criteria, 35 (24.3%) met 3 criteria, and 25 (17.4%) met all 4 criteria. Meeting the criteria for the hamstring strength LSI (P = .002), single-leg hop distance LSI (P = .004), and IKDC subjective score (P < .001) was each associated with higher ACL-RSI scores. Significant differences in ACL-RSI scores were found between patients who met none versus 2, 3, and 4 of the return-to-sport criteria (P < .001 for all) and between patients who met 1 versus 4 criteria (P < .001).

Conclusion:

Meeting return-to-sport criteria was positively associated with psychological readiness, and the patients who met multiple criteria had higher psychological readiness.

Correlation of Isokinetic Testing and ACL Failure With the Short Graft Tape Suspension Technique at Six Months

Purpose

The objective of this study was to correlate the data of the 6-month postoperative isokinetic muscle evaluation before resuming sports activities with the occurrence of ACL reconstruction rerupture after semitendinosus short graft.

Methods

From 2015 to 2018, all patients who were operated for an ACL reconstruction with a short semitendinosus autograft (TLS System) and who performed isokinetic tests on dynamometer at their 6th postoperative month were included in this study. The follow-up was prospective with the measurement of epidemiological, radiographic, and isokinetic parameters at 6 months of the ACL reconstruction. The cohort was divided into 2 groups: one group without an ACL reconstruction rerupture (Group 1) and the second group with a rerupture (Group 2).

Results

One hundred and four patients were analyzed with an average follow-up of 42.3 months (Minimum: 24; Maximum: 63.5), of which 11 patients (10.6%) had an ACL reconstruction rerupture. Group 1 consisted of 93 patients with an average age of 26.5 ± 9.0 years old who did not have an ACL reconstruction rerupture with an average follow-up of 41.6 ± 12.1 months. Group 2 consisted of 11 patients with an average age of 22.7 ± 6.1 years old, who had an ACL reconstruction rerupture with an average follow-up of 44.8 ± 11.3 months. Concerning extension force recovery, the ratio between operated and healthy knee was 81.8% ± 32.0 for Group 1, and 53.4% ± 20.6 for Group 2 (P = .035). A statistically significant difference was also found (P = .0017) during 60°/s flexion isokinetic test between the two groups.

Conclusions

This study revealed a significant link between muscle weakness in flexion and extension during 60°/s isokinetic test at 6 months of ACL reconstruction and semitendinosus autograft rerupture. Patients with an ACL reconstruction retear had inferior muscle dynamometric recovery results at 6 months before resuming sports activities.

Level of Evidence

Level III, prognostic, retrospective cohort study.

Analysis of Athletes Who Did Not Return to Play After Open Latarjet

Background:

The Latarjet procedure is indicated in patients with risk factors for postoperative recurrence, including collision and competitive athletes. However, the factors that prevent athletes from being able return to play (RTP) after the open Latarjet procedure are still unclear and have not been fully elucidated in the literature.

Purpose:

To evaluate patient-reported outcomes and psychological and psychosocial factors associated with athletes who did not RTP after the open Latarjet procedure compared with patients who did RTP.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a retrospective review of athletes who underwent the open Latarjet procedure and subsequently did not RTP after a minimum of 12 months. These patients were pair matched in a 2:1 ratio for age, sex, sport, and level of preoperative play with a control group who returned to play. Patients were evaluated for their psychological readiness to return to sport using the Shoulder Instability–Return to Sport after Injury (SIRSI); other measures included the visual analog scale (VAS) for pain and Subjective Shoulder Value (SSV). Multivariate regression models were used to evaluate factors affecting RTP.

Results:

Included were 35 patients in the no-RTP group and 70 patients in the RTP group. In the no-RTP group, 7 patients (20%) passed the SIRSI benchmark of 56, with a mean overall score of 41.5 ± 21.9; in the RTP group, 57 patients (81.4%) passed the SIRSI benchmark, with a mean overall score of 74.5 ± 19.8 (P < .0001 for both). Patients in the RTP group had better SSV (88.0 vs 75.7; P <.0001) and VAS pain (1.7 vs 2.9; P = .0046) scores. Of the athletes who did not return, 18 felt persistent pain/apprehension and 17 felt that it was a natural end to their career or that their lifestyle had changed. Multiple logistic regression revealed that thoughts of having to go through surgery and rehabilitation again was significantly associated with lower RTP (P < .05).

Conclusion:

Patients who did not RTP after open Latarjet exhibited poor psychological readiness to RTP and worse pain VAS and SSV scores compared with patients who did RTP.

Psychological Readiness to Return to Sport at 6 Months Is Higher After Bridge-Enhanced ACL Restoration Than Autograft ACL Reconstruction: Results of a Prospective Randomized Clinical Trial

Background:

Previous clinical studies have shown that psychological factors have significant effects on an athlete’s readiness to return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR).

Hypothesis:

We hypothesized that patients who underwent bridge-enhanced ACL restoration (BEAR) would have higher levels of psychological readiness to return to sport compared with patients who underwent ACLR.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 100 patients (median age, 17 years; median preoperative Marx activity score, 16) with complete midsubstance ACL injuries were randomized to either the BEAR procedure (n = 65) or autograft ACLR (n = 35 [33 hamstring and 2 bone--patellar tendon—bone]) and underwent surgery within 45 days of injury. Objective, functional, and patient-reported outcomes, including the ACL--Return to Sport after Injury (ACL-RSI) scale, were assessed at 6, 12, and 24 months postoperatively.

Results:

Patients who underwent the BEAR procedure had significantly higher ACL-RSI scores at 6 months compared with those who underwent ACLR (71.1 vs 58.2; P = .008); scores were similar at 12 and 24 months. Baseline factors independently predictive of higher ACL-RSI scores at 6 months were having a BEAR procedure and participating in level 1 sports prior to injury, explaining 15% of the variability in the scores. Regression analysis of baseline and 6-month outcomes as predictors indicated that the International Knee Documentation Committee (IKDC) score at 6 months explained 45% of the 6-month ACL-RSI variance. Subsequent analysis with IKDC excluded from the model indicated that decreased pain, increased hamstring and quadriceps strength in the surgical limb, and decreased side-to-side difference in anteroposterior knee laxity were significant predictors of a higher ACL-RSI score at 6 months, explaining 34% of the variability in scores. Higher ACL-RSI score at 6 months was associated with earlier clearance to return to sports.

Conclusion:

Patients who underwent the BEAR procedure had higher ACL-RSI scores at 6 months postoperatively. Better ACL-RSI scores at 6 months were related most strongly to higher IKDC scores at 6 months and were also associated with lower pain levels, better muscle recovery, and less knee laxity at 6 months.

Registration:

NCT02664545 (ClinicalTrials.gov identifier).

Exercise Descriptors That Determine Muscle Strength Gains Are Missing From Reported Anterior Cruciate Ligament Reconstruction Rehabilitation Programs: A Scoping Review of 117 Exercises in 41 Studies

OBJECTIVE

To (1) describe which strength training exercise descriptors are reported in anterior cruciate ligament reconstruction (ACLR) rehabilitation research, and (2) compare the current standards of reporting ACLR strength training exercise descriptors to international best-practice strength training guidelines.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the MEDLINE, PsycINFO, CINAHL, SPORTDiscus, Academic Search, ERIC, Health Source: Nursing, Health Source: Consumer, MasterFILE, and Africa-Wide Information databases.

STUDY SELECTION CRITERIA

We included level I to IV studies of ACLR rehabilitation programs with 1 or more reported strength training exercise descriptors. We used a predefined list of 19 exercise descriptors, based on the American College of Sports Medicine (ACSM) exercise recommendations, the Consensus on Exercise Reporting Template (CERT), and the Toigo and Boutellier exercise descriptor framework.

DATA SYNTHESIS

Completeness and the standard of reporting exercise descriptors in ACLR rehabilitation programs were assessed by means of international best-practice strength training standards.

RESULTS

We extracted data on 117 exercises from 41 studies. A median of 7 of the 19 possible exercise descriptors were reported (range, 3-16). Reporting of specific exercise descriptors varied across studies, from 95% (name of the strength training exercise) to 5% (exercise aim, exercise order). On average, 46%, 35%, and 43% of the exercise descriptors included in the ACSM, CERT, and Toigo and Boutellier guidelines were reported, respectively.

CONCLUSION

Key exercise descriptors for muscle strength gains are not reported in studies on ACLR rehabilitation. Only the exercise name, number of exercises, frequency, and experimental period were reported in most of the studies. J Orthop Sports Phys Ther 2022;52(2):100-112. Epub 16 Nov 2021. doi:10.2519/jospt.2022.10651.

Open Subpectoral Biceps Tenodesis May Be an Alternative to Arthroscopic Repair for SLAP Tears in Patients Under 30

PURPOSE

The purpose of the current study is to compare the outcomes of open subpectoral biceps tenodesis (BT) to arthroscopic repair (AR) for SLAP tears in patients under the age of 30 years.

METHODS

A retrospective review of patients under the age of 30 years who underwent either isolated BT or AR for a diagnosis of a SLAP tear between 2011 and 2019 was performed. Patients were included if they were >16 years old at the time of surgery, had an isolated SLAP tear involving instability of the biceps-labral anchor (types II-IV), were skeletally mature, and had a minimum follow-up of 12 months. The American Shoulder & Elbow Surgeons score, visual analog scale, Subjective Shoulder Value, patient satisfaction, willingness to undergo surgery again, revisions, and return to play (RTP) were evaluated. A P value of <.05 was considered statistically significant.

RESULTS

Our study included 103 patients in total; 29 patients were treated with BT, and 74 were treated with AR. The mean age was 24.8 years, and the mean follow-up duration was 60 months. At final follow-up, there was no difference between treatment groups in any of the functional outcome measures assessed (P > .05). Overall, there was no significant difference in the total rate of RTP (BT: 76.3%, AR: 85%; P = .53), timing of RTP (BT: 8.8 months, AR: 9.4 months; P = .61), and total rate of RTP among overhead athletes (BT: 84.2%, AR: 83.3%; P > .99). Among those undergoing AR, 9 required a revision procedure (11.5%) compared to none treated with BT (P = .11).

CONCLUSIONS

In patients under the age of 30 years with a symptomatic isolated SLAP tear, BT may be a reliable alternative to AR.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Patients unable to return to play following medial patellofemoral ligament reconstructions demonstrate poor psychological readiness

PURPOSE

Medial patellofemoral ligament reconstruction (MPFLR) is often indicated in athletes with lateral patellar instability to prevent recurrence and allow for a successful return to play. In this patient population, the ability to return to play is one of the most important clinical outcomes. The purpose of the current study was to analyze the characteristics of patients who were unable return to play following MPFL reconstruction.

METHODS

A retrospective review of patients who underwent MPFL reconstruction and subsequently did not return to play after a minimum of 12-months of follow-up was performed. Patients were evaluated for their psychological readiness to return to sport using the MPFL-Return to Sport after Injury (MPFL-RSI) score, which is a modification of the ACL-RSI score. A MPFL-RSI score > 56 is considered a passing score for being psychologically ready to return to play. Additionally, reasons for not returning to play including Visual Analog Scale for pain (VAS), Kujala score, satisfaction, and recurrent instability (including dislocations and subluxations) were evaluated.

RESULTS

The study included a total of 35 patients who were unable to return to play out of a total cohort of 131 patients who underwent MPFL reconstruction as treatment for patellar instability. Overall, 60% were female with a mean age of 24.5, and a mean follow-up of 38 months. Nine patients (25.7%) passed the MPFL-RSI benchmark of 56 with a mean overall score of 44.2 ± 21.8. The most common primary reasons for not returning to play were 14 were afraid of re-injury, 9 cited other lifestyle factors, 5 did not return due to continued knee pain, 5 were not confident in their ability to perform, and 2 did not return due to a feeling of instability. The mean VAS score was 1.9 ± 2.3, the mean Kujala score was 82.5 ± 14.6, and the mean satisfaction was 76.9%. Three patients (8.7%) reported experiencing a patellar subluxation event post-operatively. No patient sustained a post-operative patellar dislocation.

CONCLUSION

Following MPFL reconstruction, patients that do not return to play exhibit poor psychological readiness with the most common reason being fear of re-injury.

LEVEL OF EVIDENCE

IV.

Anterior Cruciate Ligament Reconstruction Using Autologous Hamstrings Augmented With the Ligament Augmentation and Reconstruction System Versus Hamstrings Alone: A Comparative Cohort Study

BACKGROUND

Few studies have reported the return-to-sports (RTS) rate in patients after augmentation of autologous anterior cruciate ligament reconstruction (ACLR) with the Ligament Augmentation and Reconstruction System (LARS).

PURPOSE/HYPOTHESIS

The purpose of this study was to compare postoperative outcomes in patients who underwent ACLR with single-bundle 4-strand hamstring autograft either without augmentation (HA-ACLR group) or with LARS augmentation (AUG-ACLR group). It was hypothesized that clinical outcomes and RTS rates would be better in the AUG-ACLR group at the 1-year follow-up, with similar outcomes in both cohorts by 2 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent ACLR between April 2014 and December 2017 were included in the current comparative study if they were skeletally mature and had 1- and 2-year follow-up outcomes; patients with concomitant meniscal surgery were also included. Included were 66 patients with AUG-ACLR (mean age, 26.8 years; 67% male) and 130 patients with HA-ACLR (mean age, 27.5 years; 61% male). Subjective outcome measures included the International Knee Documentation Committee Subjective Knee Evaluation Form, Knee injury and Osteoarthritis Outcome Score, Lysholm scale, Tegner activity scale, and the Noyes sports activity rating scale. Objective measures included knee laxity, maximal isokinetic knee flexion and extension strength, and the results of 4 functional hop tests.

RESULTS

There were no significant differences between the study groups in age, sex distribution, body mass index, time to surgery, or number of concurrent meniscal surgeries. At the 1-year follow-up, the AUG-ACLR group had a significantly higher Tegner score (P = .001) and rates of RTS (P = .029) and return to preinjury level of sport (P = .003) compared with the HA-ACLR group. At the 2-year follow-up, there were no differences in these measures between groups. There were no between-group differences in other subjective outcomes, knee laxity, or strength and hop test results at either postoperative time point. There were also no differences in rerupture rates or other complications between the groups.

CONCLUSION

Patients with AUG-ACLR had higher 1-year postoperative Tegner scores and rates of RTS and preoperative sport level compared with the HA-ACLR group. The 2-year rerupture rate for the AUG-ACLR group was low, and no intra-articular inflammatory complications were noted.

Arthroscopic Bankart Repair Versus Open Latarjet for Recurrent Shoulder Instability in Athletes

Background:

In athletes with recurrent shoulder instability, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are commonly indicated to restore stability and allow them to return to play (RTP).

Purpose:

To compare the outcomes of ABR and OL in athletes with recurrent shoulder instability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We performed a retrospective review of patients with recurrent shoulder instability who underwent ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. The patients were pair-matched in a 1:1 ratio (OL and ABR) by age, sex, sport, and level of preoperative play. We evaluated the rate, level, and timing of RTP, and the Shoulder Instability–Return to Sport after Injury (SIRSI) score between procedures. Additionally we compared the recurrence rate, visual analog scale (VAS) pain score, Subjective Shoulder Value (SSV), Rowe score, satisfaction, and whether patients would undergo the same surgery again.

Results:

Participants included 62 athletes who underwent ABR and 62 who underwent OL, with a mean follow-up of 47.7 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, SIRSI score, VAS score, SSV, or patient satisfaction. OL resulted in a significantly lower recurrence rate (1.6% vs 16.1% for ABR; P = .009) and a significantly higher Rowe score (mean ± SD, 90.5 ± 12.2 vs 82.2 ± 20.8 for ABR; P = .008). In collision athletes, there was no significant difference between ABR and OL regarding RTP rate (89.1% vs 94.5%; P = .489) or SIRSI score (70.4 ± 24.8 vs 73.8 ± 19.6; P = .426), but OL resulted in a lower recurrence rate (14.5% vs 1.8%; P = .031).

Conclusion:

ABR and OL resulted in excellent clinical outcomes, with high rates of RTP in athletes. However, lower recurrence rates were seen with OL.

Analysis of patients unable to return to play following arthroscopic Bankart repair

PURPOSE

The purpose of this study was to analyze patients that did not return to play (RTP) following arthroscopic Bankart repair (ABR) compared to those who did RTP, and analyze factors associated with not returning to play.

METHODS

A retrospective review of patients who underwent ABR, and subsequently did not RTP after a minimum of 24-month follow-up was performed. Additionally, these were pair matched in a 3:1 ratio for age, gender, sport and level of pre-operative play with a control group who RTP. Patients were evaluated for their psychological readiness to return to sport using the SIRSI score. Multivariate regression models were used to evaluate factors affecting RTP.

RESULTS

The study included a total of 52 patients who were unable to RTP and 156 who returned to play. Ten patients (19.2 %) who did not RTP passed the SIRSI benchmark of 56 with a mean overall score of 39.8 ± 24.6, in those who returned 73.0 % passed the SIRSI benchmark of 56 with a mean overall score of 68.9 ± 22.0 (p < 0.0001 for both). The most common primary reasons for not returning were 27 felt physically unable to return, whilst 21 felt it was a natural end to their career or their lifestyle had changed. Multi-logistic regression revealed that 4 of the 12 components of the SIRSI score (p < 0.05 for all) and SSV (p = 0.0049), were the factors that were associated with RTP.

CONCLUSION

Following ABR, those that do not return to play exhibit poor psychological readiness to return to play, with multi-linear regression revealing the SIRSI questions associated with fear of re-injury were associated with a lower rate of RTP. Additionally, functional limitations were found to be associated with a lower rate of RTP.

LEVEL OF EVIDENCE

Level III; Retrospective Comparative Cohort Study.

ACL Return to Sport Testing: It's Time to Step up Our Game

Patients and physicians have long looked to physical therapists to help determine an athlete's readiness to return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR). This is a complex decision that must take into account biological healing, joint stability, functional performance, and psychological readiness. Considering that the vast majority of medical professionals use time as the sole determinant of an athlete's readiness, and few are using performance-based criteria, it appears as though our profession is failing to capture the necessary information to make this weighty recommendation. The time is now to take a hard look at current practice patterns with RTS testing and push the envelope forward. The purpose of this clinical commentary is challenge our failing status quo by disseminating a robust model for RTS testing that incorporates temporal and criterion-based factors, as well as intrinsic and extrinsic data.

LEVEL OF EVIDENCE

5.

Arthroscopic Bankart Repair Versus Open Latarjet for First-Time Dislocators in Athletes

BACKGROUND

In athletes with a first-time shoulder dislocation, arthroscopic Bankart repair (ABR) and the open Latarjet procedure (OL) are the most commonly utilized surgical procedures to restore stability and allow them to return to play (RTP).

PURPOSE

To compare the outcomes of ABR and OL in athletes with a first-time shoulder dislocation.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We performed a retrospective review of patients with first-time shoulder dislocation who underwent primary ABR and OL and had a minimum 24-month follow-up. Indications for OL over ABR in this population were those considered at high risk for recurrence, including patients with glenohumeral bone loss. Patients who underwent ABR were pair-matched in a 2:1 ratio with patients who underwent OL by age, sex, sport, and level of preoperative play. The rate, level, and timing of RTP, as well as the Shoulder Instability-Return to Sport after Injury (SIRSI) score were evaluated. Additionally, we compared recurrence, visual analog scale pain score, Subjective Shoulder Value, Rowe score, satisfaction, and whether patients would undergo the surgery again.

RESULTS

Overall, 80 athletes who underwent ABR and 40 who underwent OL were included, with a mean follow-up of 50.3 months. There was no significant difference between ABR and OL in rate of RTP, return to preinjury level, time to return, or recurrent dislocation rate. There were also no differences between ABR and OL in patient-reported outcome scores or patient satisfaction. When collision athletes were compared between ABR and OL, there were no differences in RTP, SIRSI score, or redislocation rate.

CONCLUSION

ABR and OL resulted in excellent clinical outcomes, with high rates of RTP and low recurrence rates. Additionally, there were no differences between the procedures in athletes participating in collision sports.

The Role of Psychological Readiness in Return to Sport Assessment After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Knowledge about the predictive value of return to sport (RTS) test batteries applied after anterior cruciate ligament reconstruction (ACLR) is limited. Adding assessment of psychological readiness has been recommended, but knowledge of how this affects the predictive ability of test batteries is lacking.

PURPOSE

To examine the predictive ability of a RTS test battery on return to preinjury level of sport and reinjury when evaluation of psychological readiness was incorporated.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 129 patients were recruited 9 months after ACLR. Inclusion criteria were age ≥16 years and engagement in sports before injury. Patients with concomitant ligamentous surgery or ACL revision surgery were excluded. Baseline testing included single-leg hop tests, isokinetic strength tests, the International Knee Documentation Committee (IKDC) Subjective Knee Form 2000, a custom-made RTS questionnaire, and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale. The RTS criteria were IKDC 2000 score ≥85% and ≥85% leg symmetry index on hop and strength test. At a 2-year follow-up evaluation, further knee surgery and reinjuries were registered and the RTS questionnaire was completed again. Regression analyses and receiver operating characteristic analyses were performed to study the predictive ability of the test battery.

RESULTS

Out of the 103 patients who completed the 2-year follow-up, 42% returned to their preinjury level of sport. ACL-RSI 9 months after surgery (odds ratio [OR], 1.03) and age (OR, 1.05) predicted RTS. An ACL-RSI score <47 indicated that a patient was at risk of not returning to sport (area under the curve 0.69; 95% CI, 0.58-0.79), with 85% sensitivity and 45% specificity. The functional tests did not predict RTS. Six patients sustained ACL reinjuries and 7 underwent surgery for other knee complaints/injuries after RTS testing. None of the 29 patients who passed all RTS criteria, and were therefore cleared for RTS, sustained a second knee injury.

CONCLUSION

ACL-RSI and age were predictors of 2-year RTS, while functional tests were not informative. Another main finding was that none of the patients who passed the 85% RTS criteria sustained another knee injury.

Rehabilitation characteristics and patient barriers to and facilitators of ACL reconstruction rehabilitation: A cross-sectional survey

OBJECTIVES

To investigate patient-reported rehabilitation characteristics and barriers to and facilitators of ACL reconstruction rehabilitation.

DESIGN

Survey-based study.

SETTING

Online survey platform.

PARTICIPANTS

Adults 1-20 years post ACL reconstruction (n = 304).

MAIN OUTCOME MEASURES

1) rehabilitation characteristics, 2) barriers to and facilitators of rehabilitation.

RESULTS

Fear of re-injury (43.8%) was the highest rating barrier to rehabilitation adherence, while a good relationship with your rehabilitation provider was regarded as the most important factor (83.6%) in facilitating rehabilitation. Rehabilitation frequency reduced across the duration of rehabilitation from most commonly 1 x week (38.2%) in the first three months to once every month (26%) from 6 to 9 months. Almost all participants (95.7%) consulted a rehabilitation provider for the first six months. Only 43.4% of respondents returned to their previous level of sport. The exploratory analysis identified that low barriers to rehabilitation and a longer duration of supervised rehabilitation are associated with a faster return to sport, greater likelihood of return to previous level of sport and fewer reported ongoing problems with the knee.

CONCLUSIONS

This cross-sectional survey provides insight into the patient's experience of rehabilitation practices and a patient's perspective on the key barriers to and facilitators of ACL rehabilitation adherence and participation.

Psychological readiness is related to return to sport following hip arthroscopy and can be assessed by the Hip-Return to Sport after Injury scale (Hip-RSI)

PURPOSE

Psychological readiness may play an important role in the return to sport (RTS) process following hip arthroscopy (HA), but there are limited tools for the measurement of this construct. The aim of this study was to modify the Swedish version of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale for use in HA patients and evaluate its psychometric properties.

METHODS

Content validity of a modified version of the Swedish ACL-RSI (Hip-RSI) was evaluated through 127 HA patient responses and relevance ratings by an expert panel (35 patients, 9 surgeons, 11 physiotherapists). Items with low relevance were omitted. Construct validity was assessed by the association of Hip-RSI scores to hip-related sporting function (HAGOS sport) and quality of life (iHOT12). Hip-RSI scores were compared between patients who had not returned, or returned to sport participation, previous sport, and sport performance.

RESULTS

Item reduction resulted in a 6-item Hip-RSI scale with adequate content validity for the target population. Construct validity of the full and the item-reduced scale was demonstrated by correlation to HAGOS sport and iHOT12 (r 0.631-0.752). A gradient increase in Hip-RSI scores was found for patients returning to sport participation, previous sport, and sport performance.

CONCLUSION

The short version of the Swedish Hip-RSI is a valid tool for the assessment of psychological readiness to RTS and can be recommended to be used in HA patients. Higher psychological readiness to RTS, assessed by the Hip-RSI, is found with increasing levels of return to sports following HA.

LEVEL OF EVIDENCE

III.

Recovery of preoperative absolute knee extension and flexion strength after ACL reconstruction

Background

The recovery of muscle function after an Anterior Cruciate Ligament (ACL) reconstruction is most commonly reported as limb-to-limb differences using the Limb Symmetry Index (LSI), which is not free from limitations. The purpose of this study was to compare the proportion of patients who recover their Preoperative Absolute Muscle Strength (PAMS) 8 and 12 months after ACL reconstruction with the proportion of patients who recover their symmetrical knee strength. A secondary aim was to assess the relationship between psychological Patient-Reported Outcomes (PROs) and recovering PAMS at 8 and 12 months after ACL reconstruction and rehabilitation.

Method

Preoperative, 8- and 12-month results from quadriceps and hamstring strength tests and PROs for 117 patients were extracted from a rehabilitation registry. Individual preoperative peak torques from strength tests were compared with results from the 8- and 12-month follow-ups respectively. Patients were defined as having recovered their PAMS upon reaching 90% of their preoperative peak torque for both quadriceps and hamstring strength. Patients were defined as having recovered their LSI upon reaching a value ≥90% when comparing the results for their injured knee with those of their healthy knee. Correlations between the recovery of PAMS and PROs at 8 and 12 months were analyzed.

Results

There was no difference in the proportion of patients who recovered their PAMS compared with patients who recovered their LSI. In all, 30% and 32% of the patients who recovered their LSI had not recovered their PAMS at 8 months and 12 months respectively. In the patients who had recovered their PAMS, 24% and 31% had not recovered their symmetrical LSI at 8 months and 12 months respectively. There was no significant correlation between the recovery of PAMS and psychological PROs.

Conclusion

The use of both PAMS and LSI provides more detailed information on the recovery of muscle strength after ACL reconstruction. The recovery of PAMS was not correlated with psychological traits, which implies that both PROs and PAMS are important when evaluating patients after ACL reconstruction.

Trial registration

 This trial was not registered.

Hospital readmission after anterior cruciate ligament reconstruction: protocol for a systematic review and meta-analysis

INTRODUCTION

Anterior cruciate ligament (ACL) injury is one of the most common injuries of the knee. ACL reconstruction (ACLR) has been widely performed as a safe and effective treatment for ACL injuries. As there is an increasing trend in the incidence of ACL injury, hospital readmission after ACLR has attracted renewed attention for the financial burden to both patients and the healthcare system. However, information about hospital readmission after ACLR remains fragmented. Therefore, we plan to systematically review the literature to investigate the rate of, causes and risk factors for hospital readmission after ACLR, and summarise interventions to reduce hospital readmission. This article is to provide the protocol for an upcoming systematic review and meta-analysis on this important issue.

METHODS AND ANALYSIS

Reporting of this protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. Electronic databases, including PubMed, Embase and the Cochrane Library, will be systematically searched from inception to June 2020. No language restrictions will be applied. Studies will be included if they reported hospital readmission or explored the associated potential causes and risk factors for hospital readmission after ACLR. The primary outcome will be the number and time frame of hospital readmission after ACLR. Secondary outcomes will be reasons for readmission, number and types of complications, risk factors for readmission and preventive measures for readmission after ACLR. Quality assessments will be performed by using the Newcastle-Ottawa Scale (NOS). If possible, study results will be summarised in a forest plot, and heterogeneity will be tested by using the Cochran's Q and I² statistics.

ETHICS AND DISSEMINATION

No ethical approval is required because our study is not related to patients or animals. The results will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020058624.