Update on accelerated rehabilitation after anterior cruciate ligament reconstruction

How Important are Psychological Measures to Determine Readiness to Return to Sports after Reconstruction of the Anterior Cruciate Ligament? An Online Survey Study

BACKGROUND

Recent studies have suggested that psychological factors are important components of a successful return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to survey physicians with respect to their criteria used to determine readiness to RTS after ACLR and to understand the significance of psychological factors on RTS.

METHODS

A survey was designed to understand the practices of clinicians managing rehabilitation after ACLR, consisting of 25 questions divided into 3 different sections, including one section about psychological scores and factors affecting RTS. The survey was delivered to three North American organizations for orthopedic sports medicine.

RESULTS

The total number of respondents was 113. Of the respondents, 95% considered psychological tests at least "somewhat important" (33% "important", 23% selected "very important"). Routine use of psychological tests in practice was only reported by 35% of respondents. The ACL-Return to Sport after Injury Scale was the most frequently used psychological test (23%). Fear of reinjury was considered the most common patient-cited psychological factor affecting RTS. Psychological factors ranked 8th out of 9 outcomes measures in determining readiness to RTS.

CONCLUSION

This study demonstrates a discrepancy between the importance of psychological tests and the frequency of use in practice. Additional education on this topic, web-based applications, and a multidisciplinary approach may increase the usage of psychological tests to determine RTS after ACLR.

The effects of different rehabilitation training modalities on isokinetic muscle function and male athletes' psychological status after anterior cruciate ligament reconstructions

BACKGROUND

Previously, researchers reported performance enhancements following long-term plyometric training in athletes with anterior cruciate ligament reconstruction (LCA). However, the effects of combined eccentric and plyometric training on measures of isokinetic strength and psychological statues in male athletes have not been examined yet. Knowledge on the effects of combined eccentric and plyometric training help to better plan and program rehabilitations sessions and thus return-to-sports.

OBJECTIVE

This study sought to compare the effects of three different rehabilitation training programs, eccentric training (ECC), plyometric training (PLYO), or combined eccentric and plyometric training (COMB), on psychological measures (kinesiophobia [TSK-CF], functional knee assessment, knee injury and osteoarthritis outcome score [KOOS], international knee documentation committee 2000 questionnaire [IKDC], and knee flexor and extensor isokinetic muscle performance (peak torque [PT], total work, ratio [R-HQ], and ratio of total work [R-TW]) at different angular velocities post ACL surgery in male elite athletes.

METHODS

Forty elite male athletes from different sports (e.g., athletics, team sports) with ACL reconstruction participated in this study. The study started after a 14-weeks post-surgery rehabilitation program, which was identical for all subjects. After this initial rehabilitation period, athletes were randomly assigned to three experimental groups, ECC (n = 10), PLYO (n = 10), and COMB (n = 10), and a control group (CON: n = 10). Testing was conducted pre- and post-the 6-weeks intervention period and included the TSK-CF, KOOS, and IKDC. Peak torque of the knee extensors/flexors was tested at 90, 180, 240 °/s, after the 6-weeks training program only.

RESULTS

Participants' adherence rate was 100% across all groups and none reported any training or test-related injury. No significant between-group baseline differences (pre-6-weeks intervention) were observed for any of the reported psychological and muscle strength parameters. Significant group-by-time interactions were found for TSK-CF (p = 0.001, d = 2.85), KOOS (p = 0.001, d = 1.31), and IKDC (p = 0.001, d = 1.07). The post-hoc analyses indicated that COMB showed larger pre-post improvements for all psychological variables (p < 0.001, d = 2.95 to 13.15), compared with PLYO, ECC, and CON. Contrast analyses demonstrated that COMB yielded significantly greater improvements compared with CON, PLYO, ECC for all isokinetic parameters at all three angular velocities (all p < 0.001, d = 0.99 to 4.61).

CONCLUSION

The results showed that COMB induced greater gains for measures of psychological status and isokinetic muscle strength compared with single-mode PLYO and ECC in elite male athletes during a post-surgery ACL rehabilitation period. Accordingly, it is recommended to implement COMB as an effective rehabilitation means to improve knee function in male elite athletes.

TRIAL REGISTRATION

This study does not report results related to health care interventions using human participants and therefore it was not prospectively registered.

Prescription of knee braces after anterior cruciate ligament reconstruction: Fact or fiction?

Objectives: This study aims to compare the clinical results of patients rehabilitated with or without a rehabilitative knee brace (RKB) after anterior cruciate ligament (ACL) reconstruction.

Patients and methods: This retrospective, comparative study was conducted at between January 2013 and December 2017. A total of 119 patients (112 males, 7 females; mean age: 32.0±8.6 years; range, 18 to 45 years) with acute ACL ruptures treated with arthroscopic ACL reconstruction and rehabilitated with (n=56) or without RKB (n=63) participated in the study. The minimum follow-up time was 24 months. The ACL quality of life (QoL) questionnaire, Lysholm Knee Scoring Scale, and Tegner Activity Level Scale were used for the evaluation of the QoL, knee function, and activity level, respectively. The time to return to sports was recorded. The side-to-side difference in the anterior translation of the tibia was measured using a KT-1000 arthrometer.

Results: The mean follow-up time was 38.4±9.1 (range, 24 to 56) months. Baseline demographics and clinical characteristics were similar between groups. Regarding QoL, knee function, and activity level, no significant difference was observed between patients who used RKB and those who did not use it at the postoperative 12th month (p=0.95, p=0.56, p=0.98, respectively) and the latest follow-up (p=0.21, p=0.73, p=0.99, respectively). The mean time to return to sports (nearly 11 months for both groups) and side-to-side difference in the anterior tibial translation at the latest follow-up was also similar between groups (p=0.15 and p=0.15, respectively). There was no graft rupture during the follow-up in both groups. The complication rates were 7.9% and 7.1% for no brace and brace groups, respectively, without a statistically significant difference (p=0.87).

Conclusion: According to the results of this study, there was no significant difference between the rehabilitative brace and no brace groups in clinical outcomes after ACL reconstruction.

Editorial Commentary: Anterior Cruciate Ligament Reconstruction Success Must Be Defined Including Patient-Reported Outcome, Functional and Structural Outcome, Avoidance of Early Adverse Events, and Avoidance of Graft Failure

Successful anterior cruciate ligament (ACL) reconstruction requires definition. Some focus on return to sport or early return to sport. Others focus on reproduction of normal ACL anatomy or biomechanics. Recent focus includes restoration of secondary stabilizers. However, each new focus can have positive, but also adverse, consequences. In general, positive results in 4 categories are equally important for the success of ACL reconstruction: early adverse events, patient-reported outcomes, ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. We are moving the needle to achieve the "best" ACL reconstruction, but we should never change treatment based on one parameter or "fashion."

Accelerated Versus Non-accelerated Rehabilitation After Primary Anterior Cruciate Ligament Reconstruction Using Hamstring Autografts: A Systematic Review and Meta-analysis of Comparative Studies

PURPOSE

This study aimed to compare the clinical outcomes between accelerated rehabilitation (AR) and non-accelerated rehabilitation (NR) after anterior cruciate ligament reconstruction (ACLR) using hamstring autografts through a systematic review and meta-analysis.

METHODS

To compare the outcomes between AR and NR, we searched Medline, Embase, and the Cochrane Library. Studies comparing their clinical outcomes after ACLR using hamstring autografts were included. AR was characterized by the starting range of motion and weight-bearing within 3 days and return to sports within 6-9 months. A meta-analysis of clinical outcome parameters used in ≥ 3 studies was conducted.

RESULTS

Seven studies were included. The International Knee Documentation Committee subjective score was significantly higher in AR than in NR at the 3- (mean difference [MD], 7.30; 95% confidence interval [CI] 1.55-13.05; P = 0.013) and 6-month follow-ups (MD, 5.64; 95% CI 0.11-11.17; P = 0.046). The side-to-side difference in anterior tibial translation at the final follow-up assessed in four studies was significantly lower in NR than in AR (MD, 0.59; 95% CI 0.12-1.07; P = 0.015). Overall Tunnel widening at the final follow-up assessed in four studies was also smaller in NR than in AR (MD, 0.48; 95% CI 0.00-0.96; P = 0.0479). However, the mean side-to-side difference and overall tunnel widening between them was < 1 mm.

CONCLUSION

The early subjective clinical outcomes of AR after ACLR using hamstring autografts were superior to those of NR. Although tunnel widening and anterior instability were also significantly larger in AR than in NR, the difference was not clinically relevant.

The interposition of soft tissue between the cortical button and femoral lateral cortex significantly increases button migration but does not negatively affect knee stability and clinical outcome

BACKGROUND

In clinical practice, soft tissue interposition may occur during femoral graft fixation. Soft tissue interposition between the lateral femoral cortex and the cortical button may affect graft tension and related longitudinal graft motion in the tunnel. We aimed to investigate the effect of soft tissue interposition on button migration and clinical outcomes in anatomical single-bundle anterior cruciate ligament reconstruction.

METHODS

Eighty-four patients aged 18-40 years, who underwent anatomical single-bundle anterior cruciate ligament reconstruction with quadruple hamstring autograft were included. Patients were divided into two groups as Group 1 (n = 32) with soft tissue interposition between the cortical button and cortex, and Group 2 (n = 52) without soft tissue interposition. At the one-year follow-up visit, the anteroposterior knee stability of the patients was evaluated using the Lachman test and KT-2000 arthrometer, and rotational stability was assessed with the pivot shift test. The Lysholm knee score was used to evaluate the functional outcome of the patients. Relationship between tissue interposition and clinical outcome, and button migration was examined.

RESULTS

Button migration was observed in 12 patients in Group 1 (37.5%) and two patients (3.84%) in Group 2 (p < 0.001). However, no significant difference was observed between patients with and without tissue interposition or those with and without button migration regarding knee stability parameters and clinical outcome (p < 0.05).

CONCLUSIONS

Postoperative tissue interposition is found to be associated with cortical button migration during the follow-up. However, it does not affect the clinical outcome.

The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis

BACKGROUND

There is no consensus on the components of return-to-sport (RTS) testing following anterior cruciate ligament (ACL) reconstruction or whether passing RTS criteria can reduce a patient's risk of reinjury.

OBJECTIVES

To determine whether impartial, criteria-based RTS decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury).

METHODS

In this systematic review with meta-analysis, the authors conducted an electronic literature search in PubMed/MEDLINE, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses Global using database-specific vocabulary related to ACL reconstruction and return to sport. Individual study quality was assessed using the modified Downs and Black checklist, and overall quality of evidence was determined with the Grading of Recommendations Assessment, Development and Evaluation scale. Pooled risk difference (passed versus failed RTS criteria), injury incidence proportion, and the diagnostic accuracy of each RTS criterion were calculated.

RESULTS

Four studies met the selection criteria. Overall, 42.7% (95% confidence interval [CI]: 18%, 69%) of patients passed RTS criteria, and 14.4% (95% CI: 8%, 21%) of those who passed experienced a second ACL injury (graft rupture or contralateral ACL injury). There was a nonsignificant 3% reduced risk of a second ACL injury after passing RTS criteria (risk difference, -3%; 95% CI: -16%, 10%; I² = 74%, P = .610). The evidence rating of the Grading of Recommendations Assessment, Development and Evaluation scale was "very low quality," due to imprecision and heterogeneity of the pooled risk difference estimate.

CONCLUSION

Passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. The quality-of-evidence rating prevents a definitive conclusion on this question and indicates an opportunity for future research.

LEVEL OF EVIDENCE

Prognosis, Level 2a-. J Orthop Sports Phys Ther 2019;49(2):43-54. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8190.

Current practice: postoperative and return to play trends after ACL reconstruction by fellowship-trained sports surgeons

PURPOSE

Advances in anterior cruciate ligament (ACL) reconstruction have allowed for many progressions in postoperative management. However, there is no standardized protocol for immediate postoperative management or return to play. Our objective was to evaluate current trends in immediate postoperative and return to sport practices after ACL reconstruction.

LEVEL OF EVIDENCE

Cross sectional study, Level IV.

METHODS

Surveys were obtained from four large sports fellowship alumni networks. Demographics included years of practice and ACLs performed per year. Postoperative questions included weight bearing status, brace use and continuous passive motion (CPM) use. Return to play included time for return, brace use and metrics used for clearance to sport.

RESULTS

A total of 143 surveys were completed (32% response rate). Average years in practice were 15.1 years. Average ACL reconstructions performed per year was 20-50 in 44% and 50-100 in 29%. 26% used CPM in all patients, 8% if concomitant meniscal repair and 66% never. Bracing after surgery was used in 84% and 48% after return to play. Return to play was allowed at 6-9 months in 67% and overall 94% from 6 to 12 months. No consensus on return to play metrics was used, with the hop test being most important followed by specific time point after surgery.

CONCLUSION

Immediate weight bearing after surgery is commonplace with intermittent CPM use. Bracing is common postoperatively and half the time with return to play. Return to play is typically allowed after at least 6 months with no consensus on return to sport metrics. Years after fellowship and ACLs performed yearly had no correlation with postoperative practices.

Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review

Objective

To describe the criteria used to guide clinical decision-making regarding when a patient is ready to return to running (RTR) after ACL reconstruction.

Design

Scoping review.

Data sources

The MEDLINE (PubMed), EMBASE, Web of Science, PEDro, SPORTDiscus and Cochrane Library electronic databases. We also screened the reference lists of included studies and conducted forward citation tracking.

Eligibility criteria for selecting studies

Reported at least one criterion for permitting adult patients with primary ACL reconstruction to commence running postoperatively.

Results

201 studies fulfilled the inclusion criteria and reported 205 time-based criteria for RTR. The median time from when RTR was permitted was 12 postoperative weeks (IQR=3.3, range 5–39 weeks). Fewer than one in five studies used additional clinical, strength or performance-based criteria for decision-making regarding RTR. Aside from time, the most frequently reported criteria for RTR were: full knee range of motion or >95% of the non-injured knee plus no pain or pain <2 on visual analogue scale; isometric extensor limb symmetry index (LSI)>70% plus extensor and flexor LSI>70%; and hop test LSI>70%.

Conclusions

Fewer than one in five studies reported clinical, strength or performance-based criteria for RTR even though best evidence recommends performance-based criteria combined with time-based criteria to commence running activities following ACL reconstruction.

ACL reconstruction with hamstring tendon autograft and accelerated brace-free rehabilitation: a systematic review of clinical outcomes

OBJECTIVE

To investigate the clinical outcomes after hamstring tendon autograft ACL reconstruction (ACLR) with accelerated, brace-free rehabilitation.

DESIGN

Systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

DATA SOURCES

Embase, MEDLINE Ovid, Web of Science, Cochrane CENTRAL and Google scholar from 1 January 1974 to 31 January 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Study designs reporting outcomes in adults after arthroscopic, primary ACLR with hamstring autograft and accelerated, brace-free rehabilitation.

RESULTS

Twenty-four studies were included in the review. The clinical outcomes after hamstring tendon autograft ACLR with accelerated brace-free rehabilitation were the following: (1) early start of open kinetic exercises at 4 weeks in a limited range of motion (ROM, 90°-45°) and progressive concentric and eccentric exercises from 12 weeks did not alter outcomes, (2) gender and age did not influence clinical outcomes, (3) anatomical reconstructions showed better results than non-anatomical reconstructions, (4) there was no difference between single-bundle and double-bundle reconstructions, (5) femoral and tibial tunnel widening occurred, (6) hamstring tendons regenerated after harvest and (7) biological knowledge did not support return to sports at 4-6 months.

CONCLUSIONS

After hamstring tendon autograft ACLR with accelerated brace-free rehabilitation, clinical outcome is similar after single-bundle and double-bundle ACLR. Early start of open kinetic exercises at 4 weeks in a limited ROM (90°-45°) and progressive concentric and eccentric exercises from 12 weeks postsurgery do not alter clinical outcome. Further research should focus on achievement of best balance between graft loading and graft healing in the various rehabilitation phases after ACLR as well as on validated, criterion-based assessments for safe return to sports.

LEVEL OF EVIDENCE

Level 2b; therapeutic outcome studies.

A Review of the Biomechanical Differences Between the High-Bar and Low-Bar Back-Squat

Glassbrook, DJ, Helms, ER, Brown, SR, and Storey, AG. A review of the biomechanical differences between the high-bar and low-bar back-squat. J Strength Cond Res 31(9): 2618-2634, 2017-The back-squat is a common exercise in strength and conditioning for a variety of sports. It is widely regarded as a fundamental movement to increase and measure lower-body and trunk function, as well as an effective injury rehabilitation exercise. There are typically 2 different bar positions used when performing the back-squat: the traditional "high-bar" back-squat (HBBS) and the "low-bar" back-squat (LBBS). Different movement strategies are used to ensure that the center of mass remains in the base of support for balance during the execution of these lifts. These movement strategies manifest as differences in (a) joint angles, (b) vertical ground reaction forces, and (c) the activity of key muscles. This review showed that the HBBS is characterized by greater knee flexion, lesser hip flexion, a more upright torso, and a deeper squat. The LBBS is characterized by greater hip flexion and, therefore, a greater forward lean. However, there are limited differences in vertical ground reaction forces between the HBBS and LBBS. The LBBS can also be characterized by a greater muscle activity of the erector spinae, adductors, and gluteal muscles, whereas the HBBS can be characterized by greater quadriceps muscle activity. Practitioners seeking to develop the posterior-chain hip musculature (i.e., gluteal, hamstring, and erector muscle groups) may seek to use the LBBS. In comparison, those seeking to replicate movements with a more upright torso and contribution from the quadriceps may rather seek to use the HBBS in training.

Return to sport: Does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes?

PURPOSE

The purpose of this study was to determine whether patients with excellent 6-month functional testing after ACL reconstruction had (1) higher risk of subsequent ACL tears, (2) superior knee function, and (3) increased activity levels compared to those with delayed clearance for return to sports at midterm follow-up.

METHODS

A total of 223 patients underwent primary ACL reconstruction by a single surgeon and had functional and isokinetic testing performed 6 months post-operatively between 1998 and 2005. Of the 223 patients, 52 (23 %) made the excellent group and were allowed return to sport at 6 months, and the remaining 171 (77 %) constituted the delayed group. Rate of ACL graft tear and native contralateral ACL tear was compared between groups. In addition, IKDC and Tegner scores were compared at a mean 4-year follow-up.

RESULTS

The graft rupture rate was similar in the excellent group (3.8 %, n = 2) compared to the delayed group (4.7 %, n = 8; p = 0.30). However, there was a higher rate of contralateral ACL tear in the excellent group (15.4 %, n = 8 vs. 5.3 %, n = 9; p = 0.003). The excellent 6-month group had superior IKDC scores (94.3 ± 6.4 vs. 90.9 ± 9.7; p = 0.04) and Tegner scores (6.6 ± 1.8 vs. 5.7 ± 1.6; p = 0.01).

CONCLUSION

Patients with an excellent performance on their isokinetic strength and functional testing at 6 months after ACL reconstruction have superior knee function and higher activity levels at midterm follow-up. However, these patients appear to be at greater risk of contralateral ACL injury, which may be related to their increased activity level. When isokinetic and functional testing is used for return-to-sport decisions, physicians should caution patients about the risk of contralateral ACL injury for high performing patients.

LEVEL OF EVIDENCE

Retrospective Review with Control, Level III.

An Assessment of Rehabilitation Protocols following Anterior Cruciate Ligament Reconstruction: A Systematic Review

The present study provided a systematic review with meta-analysis of randomized controlled trials involving the effectiveness of various rehabilitation methods that have been implemented for the treatment of anterior cruciate ligament reconstruction (ACLR). The review of the literature revealed the following as evidence for effective ACLR rehabilitation: early intervention strategy focused on restoring range of motion, muscle strength, and ligament stability with the utilization of closed kinetic chain exercises. The literature supports the use of dynamic intraligamentary stabilization, which should also be implemented in the rehabilitation protocol within the first three months after surgery. The research suggests that the patient should undergo at least 30-90 minutes of cryotherapy immediately following ACLR surgery. There is also some evidence regarding the effectiveness of neuromuscular rehabilitation training programs, but further investigations are needed. Future research should consider the timing of rehabilitation as well as supplemental rehabilitation exercises to continue to improve the quality of care delivered to patients following ACLR.

Big Five Personality Characteristics and Adherence to Clinic-Based Rehabilitation Activities after ACL Surgery: A Prospective Analysis

PURPOSE

A prospective, longitudinal study was conducted to examine Big Five personality characteristics as predictors of adherence to clinic-based rehabilitation activities following anterior cruciate ligament (ACL) reconstruction surgery.

METHOD

Participants (72 men, 36 women) completed a questionnaire assessing Big Five personality dimensions prior to surgery. For the first 7 weeks after surgery, participants' rehabilitation session attendance was recorded and rehabilitation professionals rated participants' adherence during rehabilitation sessions..

RESULTS

Results of multiple regression analyses indicated that the 5 personality factors explained 11 percent of the variance in attendance and 17 percent of the variance in adherence ratings, that agreeableness was a significant positive predictor of attendance, and that conscientiousness and openness to experience were significant positive predictors of adherence ratings.

CONCLUSION

As a potential contributor to adherence, personality warrants consideration when implementing rehabilitation programs after ACL surgery.

Assessment of functional impairment after knee anterior cruciate ligament reconstruction using cardiorespiratory parameters: a cross-sectional study

BACKGROUND

A dynamic sub-maximum exercise with the same absolute intensity, performed with different muscle groups, may present exacerbated cardiorespiratory responses. Therefore, cardiorespiratory responses to unilateral exercise may identify bilateral differences. The purpose of this study was to verify whether the cardiorespiratory responses to lower limb exercise display counter-lateral differences, and if they could be used to assist athletes and health professionals involved in rehabilitation.

METHODS

Nine individuals participated in this cross-sectional study. They had been treated in a private rehabilitation clinic and submitted to intra-articular reconstruction of the anterior cruciate ligament. The cycling exercise with the same sub-maximal intensity and with one lower limb was used to gather data. Cardiorespiratory responses to exercise were compared between exercises performed with the involved and uninvolved limb after five minutes of exercise.

RESULTS

Cardiorespiratory responses to exercise performed with the involved limb presented higher values after five minutes of cycling: oxygen uptake (+7%), carbon dioxide production (+10%), minute ventilation (+20%), breathing frequency (+19%), ventilatory equivalent for oxygen (+14%), end-tidal pressure of O2 oxygen (+4%), end-tidal pressure of O2 carbon dioxide (-9%) and heart rate (+9%).

CONCLUSIONS

The exacerbated responses, including increase of the ventilatory equivalent and decrease of end-tidal pressure of carbon dioxide, indicate that this exercise protocol may be useful in the characterization of the functional deficit of the surgical limb during rehabilitation.

Tibial displacement and rotation during seated knee extension and wall squatting: a comparative study of tibiofemoral kinematics between chronic unilateral anterior cruciate ligament deficient and healthy knees

BACKGROUND

Following anterior cruciate ligament (ACL) rupture, the knee becomes unstable with alterations in joint kinematics including anterior tibial displacement (ATD), and internal tibial rotation. Therapeutic exercises that promote faulty kinematics should be discouraged, especially early post-reconstruction, to avoid graft stretching and possibly longer-term osteoarthritis. Our study aimed to compare ATD and tibial rotation during two commonly prescribed exercises, namely: open kinetic chain (OKC) seated extension and closed kinetic chain (CKC) single leg wall squatting in ACL-deficient and healthy knees.

METHODS

Eight ACL-deficient patients and eight healthy subjects matched for age, gender and sports history were assessed using Qualisys 3D-Motion Analysis System to track 17 infrared markers while performing a seated knee extension with 3kg weight and a unilateral wall squat. We developed a model to measure joint kinematics through 70° of knee flexion and extension. ANOVA and paired t-tests compared relative ATD and tibial rotation between exercises and groups at 10° increments of flexion and extension.

RESULTS

We found increased ATD in the wall squat compared to the seated extension (p=0.049). There was no difference in ATD between the healthy and ACL-deficient knees but overall the tibia was significantly more internally rotated (p=0.003) in ACL-deficient knees, irrespective of the exercise, possibly interfering with the screw-home mechanism.

CONCLUSIONS

CKC exercises, in particular wall squats, are not necessarily safer for patients with ACL-deficiency and possibly ACL-reconstruction; although generalization should only be made with appropriate caution. Clinicians require a detailed knowledge of the effect of exercise on knee joint kinematics.

Altered landing mechanics in ACL-reconstructed patients

PURPOSE

This longitudinal study aimed to examine whether patients with anterior cruciate ligament (ACL) reconstruction show a similar landing strategy during the single-leg hop test (SLHT) postsurgery analog to that previously identified when ACL deficient. It is hypothesized that ACL-reconstructed patients demonstrate greater trunk flexion to reduce knee joint moments at the cost of postural dynamic stability at their involved leg compared to their uninvolved leg.

METHODS

Ten ACL-reconstructed patients performed a bilateral SLHT 6 and 12 months after surgery. Landing mechanics were determined by means of a soft tissue artifact optimized, rigid, full-body model, and the margin of stability was quantified using an inverted pendulum approach. Knee extensor muscular strength (KS) was assessed during isometric maximal voluntary knee extension contractions.

RESULTS

ACL-reconstructed patients showed similar landing strategies as previously reported in their ACL-deficient state. By flexing their trunk, patients repositioned the ground reaction force vector more anteriorly in relation to the joints of the lower extremity (P < 0.05) and, in doing so, were able to transfer joint moments from the knee to the adjacent joints (P < 0.05). This upper body strategy reduced the margin of stability in the ACL-reconstructed leg during landing (P < 0.05). Twelve months after surgery, the ACL-reconstructed leg showed lower KS compared to the uninvolved leg (P < 0.05), and knee joint moment output during landing was significantly correlated to KS.

CONCLUSIONS

The results highlight the important role of KS on the interaction between trunk angle, joint kinetics, and postural dynamic stability during landing and show that ACL-reconstructed patients use an analogous feedforward strategy (e.g., more flexed trunk) to that used in their ACL-deficient state, aiming to compensate for KS deficits and thereby sacrificing postural dynamic stability and increasing the risk of loss of balance during landing maneuvers.

Predictors of adherence to home rehabilitation exercises following anterior cruciate ligament reconstruction

OBJECTIVE

Although home exercises are commonly prescribed following anterior cruciate ligament (ACL) reconstruction and are considered important in obtaining successful rehabilitation outcomes, little is known about factors associated with the completion of such exercises. Consequently, this study was designed to identify predictors of adherence to home rehabilitation exercises after ACL surgery.

METHOD

Participants (33 women, 58 men) completed indices of athletic identity, neuroticism, optimism, and pessimism before ACL surgery and measures of daily pain, negative mood, stress, and home exercise completion for 42 days postoperatively.

RESULTS

Participants reported a high level of adherence to the prescribed regimen. Home exercise completion increased significantly over time as the number of sets of prescribed home exercises declined. Personal factors were not predictive of home exercise completion. Participants completed fewer home exercises on days when they experienced more stress or negative mood.

CONCLUSIONS

Day-to-day variations in negative mood and stress may contribute to adherence to prescribed home exercises.

Quadriceps strength and weight acceptance strategies continue to improve two years after anterior cruciate ligament reconstruction

The anterior cruciate ligament (ACL) is the most commonly-injured knee ligament during sporting activities. After injury, most individuals experience episodes of the knee giving way during daily activities (non-copers). Non-copers demonstrate asymmetrical quadriceps strength and movement patterns, which could have long-term deleterious effects on the integrity of the knee joint. The purpose of this study was to determine if non-copers resolve their strength and movement asymmetries within two years after surgery. 26 Non-copers were recruited to undergo pre-operative quadriceps strength testing and 3-dimensional gait analysis. Subjects underwent surgery to reconstruct the ligament followed by physical therapy focused on restoring normal range of motion, quadriceps strength, and function. Subjects returned for quadriceps strength testing and gait analysis six months and two years after surgery. Acutely after injury, quadriceps strength was asymmetric between limbs, but resolved six months after surgery. Asymmetric knee angles, knee moments, and knee and hip power profiles were also observed acutely after injury and persisted six months after surgery despite subjects achieving symmetrical quadriceps strength. Two years after surgery, quadriceps strength in the involved limb continued to improve and most kinematic and kinetic asymmetries resolved. These findings suggest that adequate quadriceps strength does not immediately resolve gait asymmetries in non-copers. They also suggest that non-copers have the capacity to improve their quadriceps strength and gait symmetry long after ACL reconstruction.

Rehabilitation of the knee following sports injury

Rehabilitation of a knee injury is done in a criterion-based progression that is based on individual progress from one phase to another and not on a prespecified period of time. If the rehabilitation deviates from this approach, the body will react with adverse affects such as inflammation, pain, and further injury. Delay in the entire rehabilitation program will delay the athlete in meeting goals and returning to play. Phase I focuses on restoration of range of motion, pain modulation, inflammatory control, modification of activities, and gait training. Phase II is characterized by gaining full range of motion, demonstration of normal gait pattern, basic to advanced strengthening and flexibility, appropriate cardiovascular conditioning, and proprioception retraining. Phase III allows functional return to prior activity level. This phase includes a sport/occupational-specific functional progression. Utilizing a trained rehabilitation specialist will allow the athlete/individual an effective and efficient return to prior level of function.

Functional recovery after anterior cruciate ligament reconstruction: a longitudinal perspective

OBJECTIVE

To evaluate functional hop performance in subjects with an anterior cruciate ligament (ACL) reconstruction with a bone-patellar tendon-bone graft during 12, 18, 26, 39, and 52 weeks.

DESIGN

A longitudinal comparative study.

SETTING

University research laboratory.

PARTICIPANTS

Patients (N=19) were evaluated at 12, 18, 26, 39, and 52 weeks after ACL reconstruction surgery.

INTERVENTION

Testing on 5 separate occasions.

MAIN OUTCOME MEASURES

The Cincinnati Knee Rating System and analog scales, the 6-meter timed hop, crossover hop, stair hop, and vertical hop, and limb symmetry indices.

RESULTS

The uninjured and injured legs and test order were randomized. There was a significant test occasion main effect for both the Cincinnati and analog scores (P=.001). Subjective rating scores improved over the 5 testing occasions. For all 4 hop tests, test occasion and limb main effects were significant (P=.001). Paired t test comparisons at each testing occasion indicated a significant difference between the reconstructed and uninjured limb (P<.05). Furthermore, significant test occasion main effects were noted for limb symmetry indices for the 4 hop tests (P=.001). Using a score of greater than or equal to 85% as a criterion for normative limb symmetry, normative scores were recorded in the 6-m timed hop at the week 18 test occasion, the stair hop and vertical hop at the week 26 test occasion, and the crossover hop at the week 39 test occasion.

CONCLUSIONS

These hop tests showed different levels of imposed demands on the knee that could be used to assess functional recovery and readiness to resume sport.

Comparison of home versus physical therapy-supervised rehabilitation programs after anterior cruciate ligament reconstruction: a randomized clinical trial

BACKGROUND

Because of health care funding and policy changes, there is a need to examine the effects of an evolution toward patient-directed (ie, home-based) rehabilitation programs on clinical outcomes of patients undergoing anterior cruciate ligament reconstruction.

HYPOTHESIS

There will be no difference in the effectiveness of a home-based rehabilitation program and a standard physical therapy-supervised rehabilitation program in patients 3 months after nonacute anterior cruciate ligament reconstruction with bone-patellar tendon-bone grafts.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

There were 145 patients (16-59 years) who attended a presurgery education class. Home-based patients attended 4 physical therapy sessions, and physical therapy-supervised patients attended 17 physical therapy sessions over the first 12 weeks after surgery. All patients followed the same standardized rehabilitation program. Study outcome measures included active-assisted knee flexion and passive knee extension range of motion, knee range of motion during walking, KT computerized arthrometer results, and isokinetic quadriceps and hamstrings strength. Patient outcomes were dichotomized as either clinically acceptable or unacceptable. Rehabilitation programs were compared by the proportion of acceptable patients in each group.

RESULTS

The home-based group had a significantly higher percentage of patients with acceptable flexion and extension range of motion compared to the standard physical therapy group (flexion, 67% vs 47%; extension, 97% vs 83%). There were no significant differences between the groups in range of motion during walking, ligament laxity, and strength.

CONCLUSION

A structured, minimally supervised rehabilitation program was more effective in achieving acceptable knee range of motion in the first 3 months after anterior cruciate ligament reconstruction than a standard physical therapy-based program.

CLINICAL RELEVANCE

Recreational athletes undergoing nonacute anterior cruciate ligament reconstruction can successfully reach acceptable rehabilitation goals in the first 3 months after surgery with a limited number of purposeful physical therapy education sessions, allowing recreational athletes more flexibility when integrating the necessary postoperative rehabilitation into their daily activities.

Effects of closed versus open kinetic chain knee extensor resistance training on knee laxity and leg function in patients during the 8- to 14-week post-operative period after anterior cruciate ligament reconstruction

Open kinetic chain (OKC) knee extensor resistance training has lost favour in ACLR rehabilitation due to concerns that this exercise is harmful to the graft and will be less effective in improving function. In this randomized, single-blind clinical trial OKC and closed kinetic chain (CKC) knee extensor training were compared for their effects on knee laxity and function in the middle period of ACLR rehabilitation. The study subjects were 49 patients recovering from ACLR surgery (37 M, 12 F; mean age=33 years). Tests were carried out at 8 and 14 weeks after ACLR with knee laxity measured using a ligament arthrometer and function with the Hughston Clinic knee self-assessment questionnaire and single leg, maximal effort jump testing (post-test only). Between tests, subjects trained using either OKC or CKC resistance of their knee and hip extensors as part of formal physical therapy sessions three times per week. No statistically significant (one-way ANOVA, p>0.05) differences were found between the treatment groups in knee laxity or leg function. OKC and CKC knee extensor training in the middle period of rehabilitation after ACLR surgery do not differ in their effects on knee laxity or leg function. Exercise dosages are described in this study and further research is required to assess whether the findings in this study are dosage specific.

Gait retraining after anterior cruciate ligament reconstruction

OBJECTIVES

To examine the effects of 2 gait retraining protocols on the gait patterns of patients with bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstruction.

DESIGN

Randomized control, repeated-measures design.

SETTING

Private orthopedic center and research facility.

PARTICIPANTS

Sixteen patients with bone-patellar tendon-bone ACL reconstruction, randomly subdivided into 2 groups (group 1, n=8; group 2, n=8), and a healthy control group of 8 subjects.

INTERVENTION

The 16 subjects with ACL reconstruction were randomly assigned to 2 different gait retraining protocols over a 6-week training interval: (1). a protocol using a predicted stride frequency calculated from the resonant frequency of a force-driven harmonic oscillator (FDHO) model or (2). a protocol using the preferred stride frequency (PSF).

MAIN OUTCOME MEASURES

Gait analyses examining the lower-extremity kinematic, kinetic, and energetic gait patterns of each group.

RESULTS

Gait retraining with the FDHO model showed improvements in lower-extremity positions, hip and knee extensor angular impulse, and work parameters. Gait retraining with the PSF demonstrated no statistical improvements. The FDHO training protocol facilitated a greater midstance knee range of motion (ROM) and greater rates of improvement for midstance ROM, hip extensor angular impulse, and concentric hip extensor work.

CONCLUSIONS

Gait retraining with the resonant frequency of an FDHO model facilitated a greater recovery of gait function compared with training with the PSF.

Strain on the Anterior Cruciate Ligament during Closed Kinetic Chain Exercises

PURPOSE

The purpose of this investigation was to characterize the ACL strains produced during four commonly prescribed CKC exercises; the step-up, the step-down, the lunge, and the one-legged sit to stand. We hypothesized that the ACL strains produced during the lunge and one-legged sit to stand exercises (the exercises that challenge the leg musculature to a greater extent and utilize greater hip flexion) would be less than those produced during the step-up and step-down exercises.

METHODS

The strains in the anteromedial bundle of the ACL were measured while nine subjects, who had normal ligaments, performed the four exercises. Peak ACL strain values and the ACL strain patterns as a function of knee flexion angle were compared between exercises.

RESULTS

No significant differences were found between the peak ACL strain values (mean +/- SEM) between exercises (step-up: 2.5 +/- 0.36; step-down: 2.6 +/- 0.34; lunge 1.9 +/- 0.50; one-legged sit to stand: 2.8 +/- 0.27). The mean ACL strain values as a function of knee flexion angle were not significantly different. On average, there was a significant increase in ACL strain as the knee was extended for each exercise.

CONCLUSIONS

The ACL strain responses produced during these CKC exercises were equal and similar to those produced during other rehabilitation exercises (i.e., squatting, active extension of the knee) previously tested.

Beliefs and attitudes of members of the American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate ligament injury

PURPOSE

The purpose of the study was to quantify the amount of agreement among orthopaedic surgeons regarding the natural history of the anterior cruciate ligament (ACL)-deficient knee, surgery, and rehabilitation, and the treatment of these patients.

TYPE OF STUDY

Physician mail survey.

METHODS

Orthopaedic surgeons were randomly selected from the American Academy of Orthopaedic Surgeons (AAOS) directory. Only individuals who treated or referred ACL-insufficient patients for treatment within the past year were asked to complete the 3-page survey. The survey included 25 questions regarding clinical opinion. Clinical agreement was present when 80% or more of the surgeons agreed on the same response option.

RESULTS

The total number of surgeons who responded to the survey was 397 (response rate, 54.8%) and the number who had treated or referred ACL-insufficient patients in the past year was 261. Among surgeons who completed the questionnaire, the response rates to the individual questions ranged from 92% to 100%. The mean response rate for all questions was 97.4%. The mean age of the surgeons was 48.4 years, and 35.8% considered their practice to be a subspecialty in sports medicine or knee surgery. For 12 questions (48%), there was clinical disagreement among the surgeons. Surgical volume was associated with clinical opinion for 16 of 25 questions (P < or =.05).

CONCLUSIONS

Significant variation is seen in clinical opinion and decision-making regarding ACL injuries among members of the AAOS, particularly regarding whether ACL-deficient patients can participate in all recreational sports activities, that ACL reconstruction reduces the rate of arthrosis, and on the use of braces in the postoperative period. Additionally, surgeons disagreed on the effect of 4 patient characteristics (age over 40, presence of pain, irreparable meniscal tear, injury involving Workers' Compensation) on the decision to perform surgery. Areas of significant clinical uncertainty should be the focus of future research and medical education for orthopaedic surgeons who treat ACL injuries.

Functional capability is enhanced with semitendinosus than patellar tendon ACL repair

The patellar and semitendinosus tendon autograft are the two most common techniques that orthopedic surgeons use to reconstruct the anterior cruciate ligament (ACL). It has not been established, however, whether either of these techniques provides a greater functional advantage to the patient.

PURPOSE

To identify patients' functional capabilities after reconstruction of the ACL with a patellar or semitendinosus tendon autograft.

METHODS

Forty male soccer players volunteered for the study and were assigned to three homogeneous groups: individuals who had patellar tendon reconstruction (N = 15), individuals who had semitendinosus tendon reconstruction (N = 15), and a control group (N = 10). All patients had undergone surgery 2 yr before this study and received the same rehabilitation training. The testing procedures included measurement of thigh circumference, maximal isometric strength of quadriceps and hamstrings, two- and one-legged jump, squat and gait analysis. Kinetic, kinematic, and electromyographic data were collected.

RESULTS

The patellar tendon group exhibited lower (P < 0.05) coactivation of the agonist and antagonist muscles around the knee joint during the squat movement and lower stabilization- and landing degrees during the jumps. Furthermore, the patellar tendon group had a shorter stance phase and reached the first vertical maximum later with the impaired leg while walking (720.2 +/- 15.6 ms vs 740.3 +/- 14.3 ms, and 24.3 +/- 0.64% vs 22.9 +/- 0.74% of stance phase), which was not observed in the semitendinosus tendon and control groups.

CONCLUSION

Functional performance is compromised in patients who undergo a patellar tendon graft compared with a semitendinosus graft, possibly due to an altered activation of the quadriceps and hamstring muscles.

Bilateral kinematic and kinetic analysis of the squat exercise after anterior cruciate ligament reconstruction

OBJECTIVES

To characterize the bilateral lower-extremity kinematics and kinetics associated with squatting exercise after anterior cruciate ligament (ACL) reconstruction.

DESIGN

We evaluated bilaterally sagittal plane kinematics and kinetics of the ankle, knee, and hip joints during submaximal squatting exercise in rehabilitating patients after ACL reconstruction. Comparisons were performed between involved and noninvolved limbs, and regression models were created to examine the relations between the bilateral kinetic differences and time postsurgery.

SETTING

A motion analysis laboratory.

PARTICIPANTS

Eight adults (27.9+/-6.8y) with unilateral ACL reconstruction (postsurgical time, 30+/-12wk).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Sagittal plane ankle, knee, and hip peak net moments of force, maximum joint excursion angles, and peak vertical ground reaction forces.

RESULTS

Peak vertical ground reaction forces did not differ between limbs. The peak knee extensor moment generated during the submaximal squatting exercise was 25.5% greater in the noninvolved limb than in the involved limb (P=.003). The peak ankle plantarflexor moment did not differ between limbs (P=.85); however, there was a trend toward a greater hip extensor moment in the involved limb (P=.06). The ratio of the peak hip extensor moment to the peak knee extensor moment was 46.5% greater in the involved limb (P=.02). Only the peak dorsiflexion angle differed between limbs (P=.02). None of the linear models examining the relations between differences in the involved limb and noninvolved limb kinetics, and postsurgical time, were statistically significant.

CONCLUSIONS

Patients performing the squat exercise, within 1 year of ACL reconstructive surgery, used 2 strategies for generating the joint torques required to perform the movement: (1) in the noninvolved limb, patients used a strategy that equally distributed the muscular effort between the hip and knee extensors, and (2) in the involved limb, patients used a strategy that increased the muscular effort at the hip and reduced the effort at the knee. These intra- and interlimb motor-programming alterations (ie, substitution strategies) could potentially slow or limit rehabilitation, and induce strength and performance deficits.

Exercise improves early functional recovery after total hip arthroplasty

The purpose of this prospective, randomized study was to apply an 8-week customized exercise program to patients (Group E) scheduled for total hip arthroplasty, followed by a postsurgery exercise program, and show the effect on functional recovery compared with control subjects (Group C) who received no additional exercise apart from routine in-hospital physical therapy. Strength, range of motion, and physical function tests were completed by 57 patients at Week 8 and Week 1 before surgery and at Weeks 3, 12, and 24 postoperatively. No differences between the exercise and control groups were observed at baseline. By 1 week before surgery, patients in Group E had shown significant improvements for Western Ontario and McMaster Universities Osteoarthritis Index (total score, stiffness, and physical function components), and combined hip strength. Patients in Group E had improved hip flexion range of motion in the diseased hip compared with patients in Group C. Significant differences in outcome measures between Group E and Group C were observed throughout the postoperative phase from Weeks 3 to 24. The current study showed that customized perioperative exercise programs are well tolerated by patients with end-stage hip arthritis, and are effective in improving early recovery of physical function after total hip arthroplasty.

Psychological Skills and Adherence to Rehabilitation after Reconstruction of the Anterior Cruciate Ligament

Objective:

To examine the relationship between self-reported use of psychological skills and rehabilitation adherence.

Design:

Prospective correlational design.

Setting:

Outpatient physical-therapy clinic specializing in sports medicine.

Patients:

Fifty-four patients (17 women and 37 men) undergoing rehabilitation after anterior-cruciate-ligament reconstruction.

Main Outcome Measures:

An abbreviated version of the Sports Injury Survey (Ievleva & Orlick, 1991) was administered approximately 5 weeks after surgery to assess use of goal setting, imagery, and positive self-talk. Four adherence measures were obtained during the remainder of rehabilitation: attendance at rehabilitation sessions, practitioner ratings of patient adherence at rehabilitation sessions, patient self-reports of home exercise completion, and patient self-reports of home cryotherapy completion.

Results:

Goal setting was positively associated with home exercise completion and practitioner adherence ratings. Positive self-talk was positively correlated with home exercise completion.

Conclusions:

Use of certain psychological skills might contribute to better adherence to sport-injury rehabilitation protocols.

Predicting physical therapy visits needed to achieve minimal functional goals after arthroscopic knee surgery

STUDY DESIGN

Retrospective, cross-sectional regression modeling.

OBJECTIVE

To predict physical therapy visits following arthroscopic knee surgery.

BACKGROUND

The number of physical therapy visits required to achieve a set of specific minimal-level goals (full knee extension, straight leg raise, normalized gait pattern, bicycle pedaling, and independent home exercises) that are related to decreased complication rates has not previously been modeled.

METHODS AND MEASURES

A multiple regression model to predict postoperative physical therapy visits was developed using subject demographics and 2 simple clinical measures, degree of straight leg raise lag and total range of motion. All data were collected from 148 patient charts. Model validity was examined by the predicted residual sum of squares technique and a second independent sample of 157 charts.

RESULTS

Diagnosis group, surgery group, and range of motion were the significant variables predicting visits in the final model (R2 = 0.384). Results of model validation analyses using predicted residual sum of squares technique (R2 = 0.346) and the second set of data (R2 = 0.282) were satisfactory. Analysis of residuals (difference of observed and predicted visits) showed prediction of the number of physical therapy visits within 3 visits for approximately 75% of the cases in both sets of data.

CONCLUSIONS

Using the model to predict physical therapy visits following arthroscopic knee surgery was more accurate than using diagnosis alone, except for lateral retinacular release. This study demonstrates how regression models could be used to explain variance in physical therapy visits for a given set of minimal functional goals.

Reflex extension loss after anterior cruciate ligament reconstruction due to femoral "high noon" graft placement

We describe a rare case of a painful reflex extension loss due to femoral malplacement of an anterior cruciate ligament (ACL) graft in a female high-level athlete. The graft was placed on the femoral site in the "high noon" position combined with a slight medial tibial tunnel placement. The resulting anterior-posterior cruciate ligament impingement near extension caused a persistent functional extension deficit of 20 degrees. Under anesthesia, the extension loss diminished, and thus it was hypothesized that the ACL-PCL impingement during extension activates a proprioceptive reflex leading to a functional extension loss while the patient is awake. After sacrifice of the graft and subsequent replacement of the ACL, full range of motion was achieved within 2 months. After a 3-year postinjury history of 3 arthroscopies and 2 ACL reconstructions, the athlete reached her preinjury activity level again. This rare cause of a reflex extension loss due to femoral high noon graft placement has not been described previously and should be included as a differential diagnosis when evaluating patients with an extension deficit after ACL reconstruction.

Anterior cruciate ligament rupture: reconstruction surgery and rehabilitation. A nation-wide survey of current practice

A database of the current practice of anterior cruciate ligament (ACL) reconstruction surgery in Great Britain was collated from a postal survey. This survey revealed that clear trends are emerging in the United Kingdom (UK) with regard to ACL reconstruction surgery (such as the type of graft used and timing of surgery) and rehabilitation. Certain issues, however, remain controversial, including bracing and knee range of movement. Clinical outcome measures are consistently used to judge operative success, but few specialists use defined objective measurements such as the IKDC scoring system.

Open and closed kinetic chain exercises in the early period after anterior cruciate ligament reconstruction. Improvements in level walking, stair ascent, and stair descent

Thirty-seven patients who had undergone anterior cruciate ligament reconstruction were tested in a gait analysis laboratory at 2 and 6 weeks after surgery. Between test sessions, patients were randomly assigned to a course of either closed or open kinetic chain resistance exercises (3 sessions per week for 4 weeks). Gait analysis consisted of bilateral calculations of knee joint angle, moment, and power during level walking, stair ascent, and stair descent. An analysis of variance on the effects of training group and test session indicated that the only variable to be significantly affected by the type of exercise program was the amount of knee flexion at the beginning of step-up (P < 0.05). All other measures of knee angle, moment, and power (16 total variables) showed no significant difference between the exercise groups. All variables measured on the injured side showed significant improvement from test 1 to test 2 (P < 0.05), but the injured leg remained functionally deficient when compared with the uninjured leg. These data suggest that there are no clinically significant differences in the functional improvement resulting from the choice of open or closed kinetic chain exercises in the early period after this surgery.

A comparison of results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes. A two- to five-year follow-up of 429 patients

The aim of this study was to compare the results after arthroscopic anterior cruciate ligament reconstruction in female and male competitive athletes who had a pre-injury Tegner activity level of > or =7 and a non-injured contralateral anterior cruciate ligament. One hundred and thirty-three female and 296 male patients were followed at 38 (21-68) months after the index operation. All the patients were operated on by experienced knee surgeons using patellar tendon autografts and interference screw fixation. At the index operation the median age of the female patients was 23 (1645) years and the median age of the male patients was 26 (16-47) years. The reconstruction was performed a median of 10 (0-141) and 10 (0-203) months after the injury in women and men respectively. The patients were re-examined by independent observers. At the follow-up, the median Lysholm score was 89 (38-100) points in the female group and 90 (22-100) points in the male group (P=0.015). The IKDC evaluation system, subjective anterior knee pain, subjective evaluation of the results, the knee-walking test and the KT-1000 tests revealed no differences between the groups. The mean (+/-2 SD) pre-injury Tegner activity level was 8.1 (+/-1.9) (median 8 (7-10)) in the female group and 8.4 (+/-1.8) (median 9 (7-10)) in the male group (P=0.003). At the follow-up, the Tegner activity level was 6.2 (+/-3.8) in the female group and 6.8 (+/-3.6) in the male group (P=0.012). At the follow-up, the Tegner activity level had decreased by 1.9 (+/-3.8) for the women and 1.6 (+/-3.3) for the men, as compared with the pre-injury level (n.s.). The difference between the performed and the desired activity level at the follow-up was 1.1 (+/-3.2) in the female group and 0.9 (+/-3.0) in the male group (n.s.). In the female group 53/133 (40%) and in the male group 115/296 (39%) returned to the pre-injury activity level (n.s.). The median one-leg-hop quotient was 93 (0-116)% in the female group and 96 (0-130)% in the male group (P=0.006). Concomitant meniscal injuries prior to the index operation, at the index operation or during the follow-up period were found in 64/133 (48%) women and in 185/ 296 (62%) men (P<0.01). The main conclusion was that the overall results in female and male athletes were comparable two to five years after the anterior cruciate ligament reconstruction. However, concomitant meniscal injuries were more common in male than females athletes after anterior cruciate ligament injuries.

The effect of knee bracing after anterior cruciate ligament reconstruction. A prospective, randomized study with two years' follow-up

The purpose of this prospective, randomized, clinical trial was to evaluate the effect of knee bracing after anterior cruciate ligament reconstruction. Sixty patients were randomized into one of two groups: Patients in the braced group wore rehabilitative braces for 2 weeks, followed by functional braces for 10 weeks, and patients in the nonbraced group did not wear braces. Data were recorded preoperatively, and postoperatively after 6 weeks, 3 and 6 months, and 1 and 2 years. The following outcome measures were used: KT-1000 arthrometry, the Cincinnati knee score, goniometry to record range of motion, computed tomography to determine thigh atrophy, Cybex 6000 isokinetic testing to evaluate muscle strength, three functional knee tests, and a visual analog scale to evaluate pain. At all follow-up times there were no significant differences between the two groups with regard to knee joint laxity, range of motion, muscle strength, functional knee tests, or pain. However, the Cincinnati knee score showed that patients in the braced group had significantly improved knee function compared with patients in the nonbraced group at the 3-month follow-up, even though the braced group showed significantly increased thigh atrophy compared with the nonbraced group at 3 months.

The effects of the number and frequency of physical therapy treatments on selected outcomes of treatment in patients with anterior cruciate ligament reconstruction

Health care reform will quite possibly change the delivery of physical therapy by demanding physical therapists to be more accountable for providing appropriate, yet cost-effective treatment. The purpose of this study was to retrospectively compare the results after anterior cruciate ligament (ACL) reconstruction between two groups of patients with different numbers and frequencies of physical therapy visits postoperatively. Two random samples of 100 patients from a total of 1,345 patients identified as undergoing ACL reconstruction from 1990 through 1993 were included. Group A patients attended physical therapy regularly and participated in a home exercise program, while patients in Group B attended limited physical therapy visits and also performed a prescribed home exercise program. Both groups followed the same postoperative rehabilitation program for early range of motion, early weight bearing, and muscle control. The outcome variables measured 1, 6, and 12 months postoperatively included the number of structured visits to physical therapy, range of motion, isokinetic strength testing, and subjective rating. Group A averaged 20 visits in the first 6 months while Group B averaged seven visits. The results revealed no significant difference for flexion, isokinetic strength, or subjective rating. There was a significant difference for hyperextension (Group A, 2 degrees; Group B, 6 degrees). The results of this investigation indicated that by following a structured physical therapy program postoperatively, it is possible for patients to achieve a successful outcome with a limited number of routine physical therapy visits.

The effects of "decelerated" rehabilitation following anterior cruciate ligament reconstruction on a hyperelastic female adolescent: a case study

Current concepts in postoperative anterior cruciate ligament (ACL) reconstruction management include participation in an "accelerated" rehabilitation program. There are no published reports examining the effects of accelerated or conservative rehabilitation on subjects with generalized ligamentous hyperelasticity. The purpose of this case study was to examine the effects of a conservative or "decelerated" rehabilitation program on the functional outcome of a hyperelastic female adolescent athlete following ACL reconstruction. The subject was a 15-year-old female basketball player who sustained a unilateral ACL tear and underwent subsequent ACL reconstruction using a patellar tendon autograft. The subject immediately began participation in a "decelerated" rehabilitation program in which the intensity and rate of progression was decelerated, emphasizing a prolonged period of maximum graft protection. Progress was objectively quantified with a battery of diagnosis-specific tests at scheduled intervals. Results at 52 weeks postoperative revealed normal range of motion, proprioception, balance, knee stability, quadriceps strength, hamstring strength, and subjective assessment values, and only a 4.0% deficit in functional scores. Our results suggest a "decelerated" rehabilitation program may be appropriate for the population with generalized ligamentous hyperelasticity by yielding excellent functional results without compromising the integrity of the graft and, ultimately, knee stability.

The clinical and cost-effectiveness of two different programs for rehabilitation following ACL reconstruction

Patient rehabilitation following anterior cruciate ligament reconstruction is a continuing challenge for physical therapists. This study compared the effectiveness of an established protocol to a new program which included Protonics exercise. Sixty patient (42 males and 18 females; mean age = 24.7 +/- 3.9 years; age range = 19-30 years) were randomly assigned into two groups: Group 1 received the established protocol and Group 2 received a Protonics exercise regimen. Both groups were measured for the time needed for return to unrestricted activity on the basis of objective, functional, and clinical exams; all tests were repeated at a 1-year follow-up exam. Group 2 completed treatment an average of 3.3 weeks sooner than Group 1 (mean = 19.8 vs. 23.1 weeks) at an average lower cost of $990.00 per subject. All subjects had good functional outcomes at the 1-year follow-up exam. It was concluded that the Protonics exercise program was more clinically and cost-effective than the other program, although both methods were successful for postsurgical anterior cruciate ligament rehabilitation.