Clinical course and recommendations for patients after anterior cruciate ligament injury and subsequent reconstruction: A narrative review

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.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport

OBJECTIVES

To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience.

DESIGN

Cross-sectional survey.

SETTING

Online survey platform.

PARTICIPANTS

Swiss physiotherapists.

MAIN OUTCOME MEASURES

The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers.

RESULTS

A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system.

CONCLUSION

This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

Preoperative predictors for return to physical activity following anterior cruciate ligament reconstruction (ACLR): a systematic review

BACKGROUND

Rates of return to physical activity after anterior cruciate ligament reconstruction surgery are sub-optimal. Optimising presurgical treatment may improve return rates. The purpose of this systematic review was to identify modifiable preoperative predictors for return to physical activity after anterior cruciate ligament reconstruction.

METHODS

Seven electronic databases (CINAHL, MEDLINE and SPORTDiscus via EBSCOhost, AMED, PsycINFO and EMBASE via OVID and Web of Science) were searched from inception to 31 March 2023. The population of focus was adults aged 18-65 who had undergone primary anterior cruciate ligament reconstruction. Studies needed to identify at least one potential modifiable preoperative predictor variable and the relationship between the predictor(s) and return to physical activity. All time-points of assessment and study designs were included. Data extraction was completed by one reviewer and verified by a second reviewer. Two reviewers completed the risk of bias assessment using the Quality in Prognostic Studies tool and Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

The search identified 2281 studies, eight met the inclusion criteria. Five studies scored 'high', and three studies scored 'moderate' risk-of-bias. All preoperative predictors were of very low-quality evidence. Five different outcome measures were used to assess return to physical activity including Tegner, Marx, Physical Activity Scale, return to play at the elite level and return to preinjury level (undefined). This was measured between 1- and 10-years post-surgery. Nine preoperative physical, six psychosocial and five demographic/clinical factors were assessed and four were found to be predictive. These included quadriceps strength, psychological profile, patient estimated ability to return and graft type (patella tendon, BPTB).

CONCLUSION

Very-low level evidence suggests that increasing quadriceps strength, managing patient expectations of their treatment outcomes, improving motivation to resume preinjury activity levels and considering the use of a BPTB graft will support return to physical activity after ACLR.

TRIAL REGISTRATION

This study was prospectively registered in PROSPERO: CRD 42020222567.

Ecological and Specific Evidence-Based Safe Return To Play After Anterior Cruciate Ligament Reconstruction In Soccer Players: A New International Paradigm

Existing return to play (RTP) assessments have not demonstrated the ability to decrease risk of subsequent anterior cruciate ligament (ACL) injury after reconstruction (ACLR). RTP criteria are standardized and do not simulate the physical and cognitive activity required by the practice of sport. Most RTP criteria do not include an ecological approach. There are scientific algorithms as the "5 factor maximum model" that can identify risk profiles and help reduce the risk of a second anterior cruciate ligament injury. Nevertheless, these algorithms remain too standardized and do not include the situations experienced in games by soccer players. This is why it is important to integrate ecological situations specific to the environment of soccer players in order to evaluate players under conditions closest to their sporting activity, especially with high cognitive load. One should identify high risk players under two conditions: Clinical analyses commonly include assessments such as isokinetic testing, functional tests (hop tests, vertical force-velocity, profile), running, clinical assessments (range of motion and graft laxity), proprioception and balance (Star Excursion Balance Test modified, Y-Balance, stabilometry) and psychological parameters (kinesophobia, quality of life and fear of re-injury). Field testing usually includes game simulation, evaluation under dual-task conditions, fatigue and workload analysis, deceleration, timed-agility-test and horizontal force-velocity profiles. Although it seems important to evaluate strength, psychological variables and aerobic and anaerobic capacities, evaluation of neuromotor control in standard and ecological situations may be helpful for reducing the risk of injury after ACLR. This proposal for RTP testing after ACLR is supported by the scientific literature and attempts to approximate the physical and cognitive loads during a soccer match. Future scientific investigation will be required to demonstrate the validity of this approach.

Level of Evidence

5.

Variables associated with successful outcome after anterior cruciate ligament reconstruction in recreational athletes: A prospective cohort study

BACKGROUND

Anterior cruciate ligament (ACL) injury and subsequent reconstruction is common and has a profound effect on health-related quality of life. There is currently limited understanding as to which variables are associated with a successful outcome post-ACL reconstruction (ACLR) in recreational athletes.

PURPOSE

Explore the association between both patient-reported and performance-based measures, and successful outcome, post-ACLR in recreational athletes.

PROCEDURES

We sought to recruit recreational athletes within one month of a primary-ACLR for a prospective cohort study. A dichotomised patient specific functional scale of ≥9 points determined a successful outcome at nine-months post-operative. Secondary patient-reported and performance-based data were collected at baseline, three-, six-, and nine-months post-operative. The association between secondary data and the primary outcome was determined using binomial logistic regression, expressed using odds ratio (OR) and 95% confidence intervals (CI).

MAIN RESULTS

90 participants were recruited (males: 58, females: 32, mean age 32.8 years [±7.9], mean height 173.5 [±10.0], mean body mass 74.0 kg [±15.8]), 87 consented to baseline measures. 47 participants completed full data collection and 21 (45%) reported a successful outcome. Higher knee osteoarthritis outcome score (OR range 1.07-1.12) and anterior cruciate ligament quality of life (ACL-QoL) scores (OR range 1.06-1.10) were associated with a successful outcome post-ACLR at various timepoints.

CONCLUSIONS

Patient-reported, rather than performance-based, measures were associated with successful outcome nine-months post-ACLR in recreational athletes. Both patient-reported and performance-based characteristics are advocated to guide optimal return to function in clinical practice.

Comparison of Healing Effect Between Fibrin Gel Complex Bone Morphological Protein and Reconstituted Bone Xenograft After Reconstruction of Sports Ligament Injury

To study the effect of fibrin gel complex bone morphological protein (FG-BMP) and RBX on the healing of tendon-bone interface. 51 live rabbits were selected, and 51 rabbits were randomly divided into 3 groups: FG-BMP, RBX and control groups. Bilateral ACL reconstruction was performed in 51 rabbits, with different biomaterials injected at the tendon-bone interface, and none applied in the FG-BMP, RBX, and control groups. Material extraction, imaging examination, histological analysis, and biomechanical tests were conducted at 2 weeks after surgery, 6 weeks later, and 12 weeks after surgery, respectively. The tendon-interbone growth rate of rabbits using FG-BMP biomaterials and RBX biomaterials was significantly improved in the FG-BMP and RBX groups compared with the control group (P < 0.05). Histological results showed that all rabbits in the RBX group were surrounded by newborn bone tissue around the tendon-bone transplantation tendon and had a significantly greater number of newborn bone tissue than in the FG-BMP group (P < 0.05). The biomechanical test results showed that the two groups of FG-BMP biomaterials improved the maximum tension compared with the control group (P < 0.05), where the RBX tension, the difference was significant (P < 0.05), and the FG-BMP group although higher than the control group (P > 0.05). Conclusion: In the comparison of promoting tendon-bone interface healing, FG-BMP biomaterials and RBX biomaterials have significant results, especially RBX materials have obvious advantages in accelerating tendon-bone interface healing.

Current perspectives and clinical practice of physiotherapists on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction. An online survey of 538 physiotherapists

OBJECTIVES

To evaluate the perspectives and clinical practice of physiotherapists regarding rehabilitation after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Online survey.

SETTING

Survey platform.

PARTICIPANTS

Greek physiotherapists.

OUTCOME MEASURES

The survey consisted of 7 sections: participant demographics, importance of ACLR rehabilitation, clinical measurements, practice, criteria to progress rehabilitation, return to running and return to sport.

RESULTS

Significant variability in measures and criteria used for clinical decision-making were found including: limb symmetry in strength and function, knee range of motion and effusion, progression, and return to sport criteria. The majority of the practitioners (28.3%) extrapolate knee strength from hop capacity. Return to running ranged from 3 to 5 months post-operatively reflecting that this was tied to physical capacities, not time from surgery. 70.0% of the Greek physiotherapists would allow return to sport ≤9 months after ACLR. Agreement was found in using: physical measures, function, and dynamic stability in ACLR rehabilitation, but the mode and interpretation varied substantially. Less than 29.0% of the physiotherapists reported using patient-reported outcome measures in their decision-making.

CONCLUSION

Current ACLR rehabilitation practices in Greece are largely not aligned with the contemporary scientific evidence and guidelines.

Altered Knee Laxity and Stiffness in Response to a Soccer Match Simulation in Players Returning to Sport Within 12 Months After Anterior Cruciate Ligament Reconstruction

BACKGROUND

The acute effects of exercise on anterior knee laxity (AKL) and anterior knee stiffness (AKS) have been documented in healthy participants, but only limited evidence has been provided for athletes cleared to return to sports after anterior cruciate ligament (ACL) reconstruction (ACLR).

PURPOSE/HYPOTHESIS

The purpose was to determine if 45 minutes of a soccer match simulation lead to acute changes in AKL and AKS in soccer players returning to sport within 12 months after ACLR. We hypothesized that the reconstructed knee of the ACLR group would exhibit an altered response to sport-specific exercise.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 13 soccer players cleared to return to sport after ACLR and 13 healthy control soccer players matched for age, physical activity level, limb dominance, and anthropometric characteristics were recruited. To assess the effects of a standardized soccer match simulation (Soccer Aerobic Field Test [SAFT45]) on AKL and AKS, an arthrometric evaluation was carried out bilaterally before and immediately after SAFT45. To conduct a comprehensive examination of the force-displacement curve, the absolute and side-to-side difference (SSD) values of both AKL and AKS were extracted at 67, 134, and 200 N.

RESULTS

The ACLR and control groups showed similar AKL and AKS at baseline (P > .05). In response to SAFT45, laxity increased bilaterally at all force levels by 14% to 17% only in the control group (P < .025). Similarly, AKS at 134 and 200 N decreased in response to SAFT45 only in the control group (10.5% and 20.5%, respectively; P < .025). After SAFT45, the ACLR group had 1.9 and 2.5 times higher SSDs of AKS at 67 and 134 N compared with the control group, respectively (P < .025), as well as a 1.9 times higher SSD of AKS at 134 N compared with baseline (P = .014).

CONCLUSION

Soccer players at the time of return to sport after ACLR showed an altered mechanical response to a sport-specific match simulation consisting of bilaterally unchanged AKL and AKS.

CLINICAL RELEVANCE

Soccer players showing altered AKL and AKS in response to exercise after ACLR may not be ready to sustain their preinjury levels of sport, thus potentially increasing the risk of second ACL injuries.

Rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament reconstruction: An online survey

OBJECTIVES

The primary objective of the study was to investigate rehabilitation strategies of Flemish physical therapists before and after anterior cruciate ligament (ACL) reconstruction. Secondly, we aimed to investigate physical therapists' preferences on continuing education and evaluate their self-rated confidence and competence when treating patients before and after ACL reconstruction.

DESIGN

Survey-based study.

SETTING

Online survey platform.

PARTICIPANTS

Flemish physical therapists (n = 283).

MAIN OUTCOME MEASURES

The online survey consisted of a combination of 40 open- and closed-ended questions, divided across 5 sections: (1) participant demographics and clinical practice information, (2) patient population information, (3) continued education practices, (4) rehabilitation strategies, and (5) physical therapist self-rated confidence and competence to treat patients with ACL reconstruction.

RESULTS

A wide variability in rehabilitation strategies were found across the whole ACL rehabilitation continuum, which were in general not in line with best available evidence. Nevertheless, the overall self-rated confidence and competence of physical therapists treating patients before and after ACL reconstruction were high.

CONCLUSION

Our findings indicate a need to improve rehabilitation practices before and after ACL reconstruction. Advanced research dissemination and implementation are required to achieve better rehabilitation outcomes.

Current preoperative physiotherapy management strategies for patients awaiting Anterior Cruciate Ligament Reconstruction (ACLR): A worldwide survey of physiotherapy practice

BACKGROUND

Anterior cruciate ligament ruptures are the most common ligament injury to the knee with surgical reconstruction considered standard treatment. This study aimed to explore the current physiotherapy management strategies used during the preoperative phase of rehabilitation for patients awaiting anterior cruciate ligament reconstruction (ACLR).

METHODS

An anonymous survey was disseminated online via Twitter and the 'interactive Chartered Society of Physiotherapy' message board. Practising physiotherapists who treated at least one patient prior to ACLR in the past year were invited to take part. Responses were collected over a 4-week period in March 2020. Data were analysed using descriptive statistics.

RESULTS

In total, 183 respondents replied; 122 completed the full survey. Responses were collected from 20 countries across 3 settings, NHS/public health services, private and sports. Most respondents reported prescribing exercises, advice and education to patients during prehabilitation. Up to 40% also utilised passive treatments including manual therapy, taping/bracing and electrotherapy. The frequency of recommended exercise completion and length of treatment varied. Most respondents (n = 103/84.4%) felt that many patients waiting for ACLR did not receive prehabilitation. Many physiotherapists reported that patients expressed concerns regarding their readiness for surgery (n = 61/50%) and return to preinjury levels of physical activity (n = 112/91.8%). Almost all respondents would discuss non-operative management with patients (n = 112/91.8%) if they had returned to their preinjury level of physical activity before their ACLR.

CONCLUSION

Overall, this survey provides some insight as to how physiotherapists manage patients awaiting ACLR. Areas of uncertainty in physiotherapy practice have also been highlighted that require further high-quality research.

The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: a systematic review

BACKGROUND

To explore the effectiveness of preoperative rehabilitation programmes (PreHab) on postoperative physical and psychological outcomes following anterior cruciate ligament reconstruction (ACLR).

METHOD

A systematic search was conducted from inception to November 2019. Randomised controlled trials (RCTs) published in English were included. Risk of bias was assessed using Version 2 of the Cochrane risk-of-bias tool, and the Grading of Recommendations Assessment system was used to evaluate the quality of evidence.

RESULTS

The search identified 739 potentially eligible studies, three met the inclusion criteria. All included RCTs scored 'high' risk of bias. PreHab in all three RCTs was an exercise programme, each varied in content (strength, control, balance and perturbation training), frequency (10 to 24 sessions) and length (3.1- to 6-weeks). Statistically significant differences (p < 0.05) were reported for quadriceps strength (one RCT) and single leg hop scores (two RCTs) in favour of PreHab three months after ACLR, compared to no PreHab. One RCT reported no statistically significant between-group difference for pain and function. No RCT evaluated post-operative psychological outcomes.

CONCLUSION

Very low quality evidence suggests that PreHab that includes muscular strength, balance and perturbation training offers a small benefit to quadriceps strength and single leg hop scores three months after ACLR compared with no PreHab. There is no consensus on the optimum PreHab programme content, frequency and length. Further research is needed to develop PreHab programmes that consider psychosocial factors and the measurement of relevant post-operative outcomes such as psychological readiness and return to sport.

TRIAL REGISTRATION

PROSPERO trial registration number. CRD42020162754 .

Individual hop analysis and reactive strength ratios provide better discrimination of ACL reconstructed limb deficits than triple hop for distance scores in athletes returning to sport

BACKGROUND

The triple hop for distance test commonly uses a limb symmetry index (LSI) 'pass' threshold of >90% for total hop distance following anterior cruciate ligament reconstruction (ACLR). However, understanding the manner in which athletes generate and dissipate forces during consecutive hops within the test may provide greater insight into residual limb deficits. The aim of the study was to examine reactive strength ratios (RSR) of individual hops during a triple hop test in a cohort of ACLR patients at discharge prior to return-to-sport.

METHODS

Twenty male athletes (24.6 ± 4.2 years; height 175.3 ± 10.2 cm; mass 73.6 ± 14.5 kg) completed the test on both non-operated and operated limbs. Total distance hopped, contact times, flight times and RSR were collected for each hop using a floor-level optical measurement system.

RESULTS

Significant, small to moderate between-limb differences (p < 0.05; d = 0.45-0.72) were shown for triple hop distance, flight time and RSR for each hop, with lower performance consistently displayed in the operated limb. Large, significant differences in RSR were evident between hops one and two on the operated limb (p < 0.05; d = 0.97). Despite 80% of participants achieving >90% LSI for total hop distance, less than 50% of participants reached the >90% LSI threshold for RSR.

CONCLUSIONS

Standardised LSI 'pass' thresholds (>90% LSI) for triple hop distance may mask residual deficits in reactive strength performance of operated limbs; therefore, more detailed analyses of individual hop performance may be warranted to enhance return to sport criteria following ACLR.

Simplified Measurement of Maximum Strength After Knee Surgery: Application-Based Knee-Training Device Compared to Isokinetic Testing

Context

Isokinetic testing is used as a standard tool in measuring strength in professional athletes. It is often used to evaluate improvement during rehabilitation. The disadvantages of isokinetic testing include its costs, the fact that it is not portable, and its risk of injury, which makes it not suitable for early postoperative rehabilitation.

Hypothesis

The aim of this study was to investigate the relationship between the results of the isokinetic testing and the measurements of an application-based knee-training device.

Study Design

Exploratory diagnostic study.

Methods

In this monocentric study, 100 subjects performed an isokinetic maximum strength examination and an assessment on the application-based knee-training device in a randomized order. The isokinetic testing was based on the Swiss Olympic protocol with 3 sets of 5 repetitions of maximum strength testing for flexion and extension. The subjects consisted of 50 healthy professional athletes and 50 healthy recreational athletes, half male and half female, between the ages of 18 to 30 years old.

Results

No medical or technical issues were reported. The analysis of the relationship between application-based knee-training device and extension showed a Pearson correlation coefficient of r=0.667 for the left knee and r=0.604 for the right knee. For flexion, the Pearson correlation coefficient was r=0.640 for the left side and r=0.673 for the right side. When strength measured by the application-based knee-training device was adjusted for height and weight of the subjects, the Pearson correlation was even stronger (extension left: r=0.727, right: r=0.689; flexion left: r=0.641, right: r=0.711).

Conclusion

The study shows a moderate to high correlation between isokinetic testing and the application-based knee-training device. These results suggest that the application-based knee-training device is effective for early strength rehabilitation without the risk of injury.

Return to Sport Tests' Prognostic Value for Reinjury Risk after Anterior Cruciate Ligament Reconstruction: A Systematic Review

INTRODUCTION

Return to sports (RTS) clearance after anterior cruciate ligament (ACL) reconstruction typically includes multiple assessments. The ability of these tests to assess the risk of a reinjury remains unknown.

PURPOSE

To assess and rate RTS self-reported function and functional tests on prognostic value for reinjury risk after ACL reconstruction and RTS.

STUDY DESIGN

Systematic review on level 2 studies.

METHODS

PubMed, Web of Knowledge, Cochrane Library, and Google Scholar databases were searched for articles published before March 2018. Original articles in English or German that examined reinjury risks/rates after primary (index) ACL injury, ACL reconstruction, and RTS were included. All RTS functional tests used in the included studies were analyzed by retrieving an effect size with predictive value (odds ratio, relative risk (risk ratio), positive predictive value, positive likelihood ratio, or hazard rate).

RESULTS

A total of 276 potential studies were found; eight studies (moderate to high quality) on 6140 patients were included in the final analysis. The reinjury incidence recorded in the included studies ranged from 1.5% to 37.5%. Four studies reported a combination of isokinetic quadriceps strength at different velocities and a number of hop tests as predictive with various effect sizes. One reported isokinetic hamstring to quadriceps ratio (hazard rate = 10.6) as predictive. Two studies reported functional questionnaires (knee injury and osteoarthritis outcome score and Tampa Scale of Kinesiophobia-11; RR = 3.7-13) and one study showed that kinetic and kinematic measures during drop vertical jumps were predictive (odds ratio, 2.3-8.4) for reinjury and/or future revision surgery.

CONCLUSIONS

Based on level 2 evidence, passing a combination of functional tests with predetermined cutoff points used as RTS criteria is associated with reduced reinjury rates. A combination of isokinetic strength and hop tests is recommended during RTS testing.

Changes in the sensorimotor system and semitendinosus muscle morphometry after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study with 1-year follow-up

PURPOSE

To evaluate the time course of sensorimotor integration processes involved in balance capability during 1-year follow-up after arthroscopic anterior cruciate ligament (ACL) reconstruction. To evaluate whether an association exists between balance performance and semitendinosus muscle morphometry features.

METHODS

Twenty-seven patients (mean age 29.6 ± 10.8 years) were prospectively followed with stabilometry and ultrasound at 3 months (T0), 6 months (T1), and 1 year (T2) after arthroscopic ACL reconstruction. Body sway and sensorimotor integration processes were evaluated by calculating the percentage difference of sway (PDS) on two surface conditions.

RESULTS

A significant difference in PDS was observed over time (p < 0.001). The interaction "Time × Condition" showed significant differences (p = 0.02), with worse performance on the compliant than the firm surface. There was a significant difference in CSA (p < 0.001), MT (p < 0.001), and %HRD (p < 0.001) over time. The interaction "Time*side" was significant for CSA (p = 0.02) and %HRD (p = 0.01). A negative correlation between PDS on compliant surface and CSA was measured at 3- (r = - 0.71, n = 27, p < 0.001) and 6-month post-surgery (r = - 0.47, n = 27, p = 0.013).

CONCLUSIONS

Balance was regained within the first 6 months after surgery, while morphometry of the semitendinosus muscle improved mostly between 6 and 12 months in patients who returned to sports activities. Balance capabilities paralleled semitendinosus muscle morphometry improvements. The instrumental assessment of sensorimotor integration processes is relevant in clinical practice as screening tests for primary and secondary prevention of ACL injury.

LEVEL OF EVIDENCE

Prospective studies, Level II.