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Smiley T, Dallman J, Long R, Kapple M, Aldag L, Mok A, Bernard C, Martin K, Vopat L, Vopat B. Lower extremity return to sport testing: A systematic review. Knee 2024; 50:115-146. [PMID: 39163752 DOI: 10.1016/j.knee.2024.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 07/04/2024] [Accepted: 07/18/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Lower extremity injuries account for an enormous portion of sports medicine cases in the United States each year. Unfortunately, there are no uniform criteria for athletes to complete prior to returning to sport (RTS) following a lower extremity injury. Therefore, the purpose of this systematic review is to review current literature for joint-specific and global lower extremity testing to determine the most valid functional test that can be utilized to reduce the risk of re-injury as athletes RTS. METHODS A systematic search of PubMed, PubMed Central, Cochrane Library, OVID, and Embase databases was conducted for studies prior to May 2024 following PRISMA guidelines. ROBINS-I Tool was utilized for the risk of bias assessment. RESULTS Of 19,189 studies, 114 (0.6%) studies published prior to May of 2024 met inclusion criteria and were analyzed. Eighty five percent of articles discussed RTS for individuals with knee pathology. Furthermore, 82% specifically analyzed RTS following ACL reconstruction. The most common RTS test was isokinetic dynamometry testing which is seen in 73% of studies. Only 6.2% of studies analyzed RTS for individuals with hip pathology and only two studies analyzed RTS for patients with ankle injuries. CONCLUSION Even with the enormous amount of literature that exists regarding ACL injuries and testing there is no standardized criterion for RTS clearance. The suggested test batteries from this review can serve as a framework for future research and validation for joint-specific RTS functional testing.
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Affiliation(s)
- Traci Smiley
- University of Kansas Medical Center, 2060 W 39th Ave, Kansas City, KS 66103, USA.
| | - Johnathan Dallman
- University of Kansas Medical Center Department of Orthopedic Surgery, 3004 Cambridge Road, Kansas City, KS 66103-2937, USA.
| | - Rachel Long
- University of Kansas School of Medicine, 3004 Cambridge Road, Kansas City, KS 66160-7300, USA.
| | - Mason Kapple
- University of Kansas School of Medicine, 3004 Cambridge Road, Kansas City, KS 66160-7300, USA.
| | - Levi Aldag
- University of Kansas School of Medicine, 3004 Cambridge Road, Kansas City, KS 66160-7300, USA.
| | - Anthony Mok
- University of Kansas School of Medicine, 3004 Cambridge Road, Kansas City, KS 66160-7300, USA.
| | - Christopher Bernard
- University of Kansas Medical Center Department of Orthopedic Surgery, 3004 Cambridge Road, Kansas City, KS 66103-2937, USA.
| | - Kyle Martin
- University of Kansas Medical Center, 2060 W 39th Ave, Kansas City, KS 66103, USA.
| | - Lisa Vopat
- University of Kansas Medical Center Department of Orthopedic Surgery, 3004 Cambridge Road, Kansas City, KS 66103-2937, USA.
| | - Bryan Vopat
- University of Kansas Medical Center Department of Orthopedic Surgery, 3004 Cambridge Road, Kansas City, KS 66103-2937, USA.
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Welling W. Return to sports after an ACL reconstruction in 2024 - A glass half full? A narrative review. Phys Ther Sport 2024; 67:141-148. [PMID: 38749349 DOI: 10.1016/j.ptsp.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 06/10/2024]
Abstract
A successful return to sports (RTS) after an anterior cruciate ligament reconstruction (ACLR) is multifactorial, and therefore difficult and challenging. Unfortunately, low percentages of patients RTS, and for those who succeed, one-fifth of patients will sustain a second ACL injury. Over the past years, test batteries were developed to assess whether patients can RTS with a low risk for a second ACL injury risk. Low rates of patients who meet RTS criteria were found, coupled with the insufficiency of current RTS test batteries in predicting second ACL injuries suggesting poor sensitivity. The result of an RTS test is likely to reflect the content of a rehabilitation program, raising critical questions regarding what we are offering patients within the rehabilitation programme. Are we preparing our patients well enough for the high demands of complex situations within pivoting team sports? This narrative review offers insights from key lessons of the last 15 years on 1) RTS testing, 2) the content of rehabilitation, and 3) the RTS continuum, all from a "helicopter perspective".
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Affiliation(s)
- Wouter Welling
- Pro-F Fysiotherapie, Kotkampweg 65, 7531 AS, Enschede, the Netherlands; University of Groningen, University Medical Center Groningen, Center for Human Movement Science, A. Deusinglaan 1, 9713 AV, Groningen, the Netherlands.
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Legnani C, Del Re M, Peretti GM, Borgo E, Macchi V, Ventura A. Limb asymmetries persist 6 months after anterior cruciate ligament reconstruction according to the results of a jump test battery. Front Med (Lausanne) 2024; 11:1303172. [PMID: 38444418 PMCID: PMC10913088 DOI: 10.3389/fmed.2024.1303172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/29/2024] [Indexed: 03/07/2024] Open
Abstract
Objectives Test batteries used to assess a patient's return-to-sports (RTS) following anterior cruciate ligament reconstruction (ACLR) are currently undergoing continual development, although no consensus exist on tests to be administered to athletes before allowing return to play. A simple standardized jump test battery was developed to objectively evaluate knee function following ACLR, thereby aiding in RTS decision-making. Methods Thirty-three patients who underwent ACLR were prospectively assessed pre-operatively, 6, and 12 months after surgery. Knee function was assessed using a device for optical detection using a test battery consisting of three jump tests: monopodalic countermovement jump (CMJ), drop jump, and monopodalic side-hop. Limb symmetry index (LSI) was reported for all tests at all time points. LSI ≥90% was defined as RTS criteria. Results At 12-month evaluation, mean LSI significantly improved compared to 6-month follow up (p < 0.01), and also compared to baseline (p < 0.01), reporting a mean value of 92.6% for CMJ, 90.6 for drop jump and 96.9% for side hop test. Most patients fulfilled the RTS criteria 12 months after surgery (LSI ≥90%). The percentages of patients demonstrating LSI ≥90% at 6 months was 7/33 (21.2%) for CMJ, 12/33 (36.4%) for drop jump, and 11/33 (33.3%) for side-hop test. One year after surgery, percentages grew up to 66.6% (22/33), 63.6% (21/33), and 81.8% (27/33) respectively. Conclusion Six months after ACLR, knee functional performance was unsatisfactory in most patients, whereas a significantly higher percentage of patients met RTS criteria 1 year after surgery. The results of the jump test battery proposed in this study support the idea that timing for resumption of cutting and pivoting sports should be delayed later than 6 months, as still limb asymmetries persist at this time point.
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Affiliation(s)
| | | | - Giuseppe M. Peretti
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Enrico Borgo
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Buldo-Licciardi M, Rynecki ND, Rao N, Eskenazi J, Montgomery SR, Li ZI, Moore M, Alaia MJ, Strauss EJ, Jazrawi LM, Campbell KA. Psychological Readiness to Return to Sport (RTS) and RTS Rates Are Similar in Patients After Either Bilateral or Unilateral Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2024; 6:100823. [PMID: 38162590 PMCID: PMC10755276 DOI: 10.1016/j.asmr.2023.100823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 10/21/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR. Methods The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts. Results In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years (P = .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P = .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P = .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P = .21), or time to return (41.2 ± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P = .31) between the 2 cohorts. Conclusions Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Michael Buldo-Licciardi
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Nicole D. Rynecki
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Naina Rao
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Jordan Eskenazi
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Samuel R. Montgomery
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Zachary I. Li
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Michael Moore
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Michael J. Alaia
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Eric J. Strauss
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Laith M. Jazrawi
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
| | - Kirk A. Campbell
- Department of Orthopedic Surgery, New York University School of Medicine, New York, New York, U.S.A
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Aizawa J, Hirohata K, Ohji S, Mitomo S, Ohmi T, Koga H, Yagishita K. Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) subcategories are affected by subjective running ability and medial single-leg hop distance in postreconstruction patients at 6 months. J Exp Orthop 2024; 11:e12004. [PMID: 38455451 PMCID: PMC10903433 DOI: 10.1002/jeo2.12004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 01/08/2024] [Indexed: 03/09/2024] Open
Abstract
Purpose This study aimed to investigate the intricate relationship between physical function factors and each subcategory score of the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale among patients following ACL reconstruction. Methods Participants comprised 59 patients who had undergone primary ACL reconstruction using hamstring tendon. The ACL-RSI was completed 6 months after reconstruction and five physical functions were measured in patients on the same day. Simple linear regression was performed multiple times to investigate the relationship between ACL-RSI subcategory scores as a dependent variable and each independent variable (knee strength, leg anterior reach distance, single-leg hop [SLH] distances, side bridge endurance, and subjective running ability). Multiple regression analysis was performed using a stepwise method, with factors showing a risk rate <0.05 in simple linear regression analyses as independent variables and the ACL-RSI in each subcategory score as the dependent variable. Results Multiple regression analysis showed that subjective running ability affected all subcategories (p ≤ 0.001), and that the limb symmetry index of medial SLH distance affected both the Emotions (p = 0.047) and Confidence (p = 0.009) subcategories. Higher subjective running ability and greater limb symmetry in the medial SLH were thus positively associated with each dimension of psychological readiness. Conclusions This study highlights the differential impact of physical function factors on specific subcategories of the ACL-RSI scale, providing clinicians with insights for designing targeted rehabilitation strategies. This original paper suggests the importance of analysing factors related to subcategory scores in addition to total ACL-RSI score, and could contribute to the understanding of determinants for a successful return to sport following ACL reconstruction. Level of Evidence Level IV.
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Affiliation(s)
- Jun‐ya Aizawa
- Department of Physical TherapyJuntendo UniversityTokyoJapan
- Department of Rehabilitation Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Kenji Hirohata
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Shunsuke Ohji
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Sho Mitomo
- Department of Rehabilitation Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
- Japan Sports AgencyTokyoJapan
| | - Takehiro Ohmi
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental SciencesTokyo Medical and Dental UniversityTokyoJapan
| | - Kazuyoshi Yagishita
- Clinical Center for Sports Medicine and Sports DentistryTokyo Medical and Dental UniversityTokyoJapan
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Suzuki M, Ishida T, Matsumoto H, Kaneko S, Inoue C, Aoki Y, Tohyama H, Samukawa M. Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction. Orthop J Sports Med 2023; 11:23259671231195030. [PMID: 37693806 PMCID: PMC10492488 DOI: 10.1177/23259671231195030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/03/2023] [Indexed: 09/12/2023] Open
Abstract
Background Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return. Purpose To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR. Study Design Case-control study; Level of evidence, 3. Methods A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS Results Significant differences were found among the RTS≥Pre, RTS Conclusion The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.
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Affiliation(s)
- Makoto Suzuki
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Tomoya Ishida
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Hisashi Matsumoto
- Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Satoru Kaneko
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Chiharu Inoue
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Yoshimitsu Aoki
- Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | | | - Mina Samukawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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Legnani C, Del Re M, Peretti GM, Macchi V, Borgo E, Ventura A. Drop Jump Performance Improves One Year Following Anterior Cruciate Ligament Reconstruction in Sportsmen Irrespectively of Psychological Patient Reported Outcomes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:5080. [PMID: 36981988 PMCID: PMC10049645 DOI: 10.3390/ijerph20065080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/10/2023] [Accepted: 03/12/2023] [Indexed: 06/18/2023]
Abstract
Our study aims to prospectively report the functional outcomes of 31 sportsmen following anterior cruciate ligament (ACL) reconstruction, up to 12 months after surgery, with regards to subjective tests and drop jump performance, and to investigate the correlations between these variables, to be used for determining the return to sports after ACL reconstruction. Lysholm score, Tegner activity level, and the ACL-Return to Sport after Injury (ACL-RSI) scale were evaluated preoperatively, at 6 months, and at 12 months after surgery. Drop vertical jump was recorded using an infrared optical acquisition system. Lysholm and ACL-RSI scores significantly improved at the 12-month follow-up compared to the baseline and 6-month evaluations (p < 0.001). Concerning Tegner activity level, no statistically significant differences were reported between pre- and post-operative status (p = 0.179). Drop jump limb symmetry index significantly improved at 12 months, with the mean value improving from 76.6% (SD: 32,4) pre-operatively to 90.2% (SD: 14.7; p < 0.001) at follow-up. Scarce positive correlation was reported between the ability to perform drop jumps and activity level in athletes one year after ACL reconstruction. In addition, subjective knee score and psychological readiness were not related to jumping performance.
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Affiliation(s)
- Claudio Legnani
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Matteo Del Re
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Giuseppe M. Peretti
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
| | - Vittorio Macchi
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Enrico Borgo
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Alberto Ventura
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
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Legnani C, Del Re M, Viganò M, Peretti GM, Borgo E, Ventura A. Relationships between Jumping Performance and Psychological Readiness to Return to Sport 6 Months Following Anterior Cruciate Ligament Reconstruction: A Cross-Sectional Study. J Clin Med 2023; 12:jcm12020626. [PMID: 36675557 PMCID: PMC9866224 DOI: 10.3390/jcm12020626] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 01/15/2023] Open
Abstract
Background: Investigating the relationship between functional capacity and psychological readiness is of paramount importance when planning sport resumption following knee surgery. The aim of this study was to prospectively assess clinical and functional outcomes in athletes 6 months after primary anterior cruciate ligament (ACL) reconstruction and to evaluate whether jumping ability is related to psychological readiness to return to sport following ACL surgery. Methods: Patients who underwent ACL reconstruction were prospectively enrolled and evaluated pre-operatively and 6 months after surgery. Assessment included Lysholm score, International Knee Documentation Committee (IKDC) Subjective Knee Form, Tegner activity level, and the ACL−Return to Sport after Injury (ACL-RSI) scale. Jumping ability was instrumentally assessed by an infrared optical acquisition system using a test battery including mono- and bipodalic vertical jump and a side hop test. Patients were dichotomized by ACL-RSI into two groups: group A (ACL-RSI > 60), and group B (ACL-RSI < 60). Results: Overall, 29 males and two females from the original study group of 37 patients (84%) were available for clinical evaluation. Mean age at surgery was 34.2 years (SD 11.3). Mean body mass index (BMI) was 25.4 (SD 3.7). Mean overall Lysholm, IKDC, and ACL-RSI scores increased from pre-operatively (p < 0.001). No differences in Tegner score were reported (p = 0.161). Similarly, improvement in most variables regarding jumping ability were observed at follow-up (p < 0.05). According to ACL-RSI, 20 subjects were allocated in group A (ACL-RSI > 60), while 11 were allocated in group B (ACL-RSI < 60). A statistically significant difference in favor of patients in group A was recorded for the post-operative Lysholm and Tegner score, as well as Side Hop test LSI level (p < 0.05), while a trend for IKDC was observed without statistical significance (p = 0.065). Conclusions: Patients with higher values of ACL-RSI scores showed better functional and clinical outcomes as well as improved performance 6 months after ACL reconstruction
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Affiliation(s)
- Claudio Legnani
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Correspondence:
| | - Matteo Del Re
- Department of Orthopedics and Traumatology, University of Milan, 20133 Milan, Italy
| | - Marco Viganò
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Giuseppe M. Peretti
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
- Department of Biomedical Sciences for Health, University of Milan, 20133 Milan, Italy
| | - Enrico Borgo
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
| | - Alberto Ventura
- Sport Traumatology and Minimally Invasive Surgery Center, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy
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