Psychological and Functional Readiness for Sport Following Advanced Group Training in Patients With Anterior Cruciate Ligament Reconstruction

Impact of Psychological Factors on Rehabilitation After Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

Anterior cruciate ligament (ACL) tears are a common orthopaedic injury, and the incidence of ACL reconstruction (ACLR) continues to increase. Current clinical practice guidelines (CPGs) recognize the role of psychological factors in rehabilitation, but patient-reported outcome measures (PROs) and psychological readiness are rarely incorporated into rehabilitation.

OBJECTIVE

The purpose of this review was to highlight the importance of psychological health after ACL injury, understand the current metrics used to monitor psychological recovery, and outline how psychological recovery can be better incorporated in current CPGs.

DATA SOURCES

A systematic review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines (PRISMA); 63 studies were identified with a PubMed search using the term "ACL Injuries/psychology".

STUDY SELECTION

Exclusion criteria included lack of consideration of psychological effects or studies validating PROs after ACLR. Studies were reviewed by multiple reviewers, and a total of 38 studies were included after applying exclusion criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 3b.

DATA EXTRACTION

Two independent reviewers analyzed the included articles to extract sample size, psychological readiness scale or other measures used, and key results.

RESULTS

Psychological outcomes, especially kinesiophobia and fear of reinjury, are seen commonly after ACLR. Psychological factors were shown to impede return to sport (RTS), alter measurable knee biomechanics, and potentially increase the risk for re-rupture. Targeted interventions such as kinesiotaping, knee bracing, and imagery training can help improve psychological and functional testing after ACLR.

CONCLUSION

ACLR is often complicated by psychological factors. Psychological readiness is a crucial yet often unincorporated part of rehabilitation. Patients with higher levels of kinesiophobia and lower psychological readiness to RTS specifically should be identified to allow for administration of interventions, such as imagery training, knee bracing, or kinesiotaping, that can mitigate the negative effects of psychological outcomes and improve recovery.

Patients undergoing multiligament knee reconstruction injured during pivoting sports demonstrate similar clinical, functional and return to sport outcomes by 2 years compared with those undergoing anterior cruciate ligament reconstruction

PURPOSE

This study investigates the clinical and activity-based outcomes after anterior cruciate ligament reconstruction (ACLR) versus multiligamentous knee reconstruction (MLKR) following a pivoting sports injury.

METHODS

Fifty MLKR patients were included, of which 20 (40%) were injured during pivoting sports. A further 50 patients undergoing ACLR following an injury during pivoting sports were consecutively recruited for comparison. Patients were assessed before the surgery and at 6-, 12- and 24 months with patient-reported outcome measures (PROMs) including the International Knee Documentation Committee (IKDC) form, Tegner activity scale (TAS) and anterior cruciate ligament return to sport after injury (ACL-RSI) score. Knee movement, the single (SHD) and triple (THD) hop tests for distance, and peak isokinetic knee extensor and flexor strength were assessed, with Limb Symmetry Indices (LSIs) calculated. Outcomes were compared across groups: (1) ACLR (n = 50), (2) MLKR (n = 50) and (3) MLKR due to pivoting sport injury (n = 20).

RESULTS

IKDC, TAS and ACL-RSI scores remained lower (p < 0.05) in the full MLKR versus ACLR cohort at all timepoints. Comparing the ACLR and MLKR cohort that had injuries specifically during pivoting sports, the IKDC (p < 0.001) and TAS (p = 0.009) were higher in the ACLR group at 6 months, and the ACL-RSI was higher at 6 (p < 0.001) and 12 (p = 0.007) months, there were no further differences. Hop and knee extensor strength LSIs were lower (p < 0.05) in the full MLKR (versus ACLR) cohort at all timepoints (apart from the 24-month SHD LSI). However, the ACLR group only demonstrated greater LSIs than the pivoting sport MLKR for the SHD at 6 months (p < 0.001), and knee extensor strength at 6 (p < 0.001) and 12 (p < 0.001) months.

CONCLUSIONS

While the recovery of patients undergoing MLKR due to a pivoting sports injury is delayed compared with their ACLR counterparts, the clinical outcome and activity profile are similar by 24 months.

LEVEL OF EVIDENCE

Level IV.

Reason Profiles for not Returning to Preinjury Activity Level Following Anterior Cruciate Ligament Reconstruction- A Latent Class Analysis With Subgroup Comparison of Patient-Reported Outcome Measures

Background

Given the high proportion of athletes who do not return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR), strategies are needed to identify at-risk patients and optimize rehabilitation for successful RTS after ACLR.

Purpose/Hypothesis

This study used latent class analysis (LCA) to characterize a unique clustering of reasons why athletes do not return to their preinjury activity level after ACLR. We hypothesized that patients with high pain scores and high levels of fear would be less likely to return to their preinjury activity level.

Study Design

Cohort study; Level of evidence, 3.

Methods

All patients at a single institution who underwent primary ACLR between 2005 and 2021 were contacted to complete a survey via REDCap. Patients' ability to RTS and their preinjury activity level, reasons for inability to return to the preinjury activity level, and patient-reported outcome scores were collected from 981 patients. LCA was performed to identify and compare patterns among patients' reasons for not returning to the preinjury activity level.

Results

Of the 981 patients included, only 446 (45.5%) were fully able to return to their preinjury activity level. LCA categorized patients into 3 groups based on their reasons for not returning to preinjury activity levels: a high-function group (75.5%), which reported no barriers; a multisymptom group (16.1%), which cited pain, lack of strength, and instability; and a fear-limited group (8.4%), which reported fear as the sole reason. Among the high-function group, 86.2% reported RTS compared with <36.7% in the other classes. There was no difference in Knee injury and Osteoarthritis Outcome Score (KOOS) subscales-including Pain, Symptoms, or Activities of Daily Living-between the high-function and fear-limited groups; however, the multisymptom group presented with the lowest scores in all KOOS subscales (P < .001). In addition, patient characteristics, the time from the index ACLR to the follow-up, and subsequent revision ACLR were similar between groups; however, the multisymptom profile demonstrated the highest proportion of allograft ACLR (P = .04) and secondary ipsilateral surgery (P < .001). Overall subjective knee grade (1-100) and Marx scores were highest in the high-function group, followed by fear-limited and multisymptom groups (P < .001).

Conclusion

Patients were differentiated into 3 distinct classes after primary ACLR. Furthermore, those with patient-reported characteristics of pain, lack of strength, instability, or fear were significantly less likely to return to their preinjury activity level or sport.

Return to Sport Following Anterior Cruciate Ligament Reconstruction: A Scoping Review of Criteria Determining Return to Sport Readiness

PURPOSE OF REVIEW

Provide a concise review of currently utilized functional metrics and patient reported outcomes measures (PROMs) determining appropriate return to sport following anterior cruciate ligament reconstruction (ACLR).

RECENT FINDINGS

When determining return to sport following ACLR, a limb symmetry index (LSI) ≥ 90% when compared to the contralateral extremity is the most commonly reported functional metric. LSI is most commonly assessed using isokinetic quadriceps strength, followed by single-leg vertical hop and cross-over hop test. A minimum ACL-Return to Sport Index (ACL-RSI) score of 68.2 was reported, as well as a mean International Knee Documentation Committee (IKDC) score of 88.3%. A minimum Knee Injury and Osteoarthritis Outcome Score-Quality of Life (KOOS-QoL) of 62.5% was reported in a single investigation. There remains limited data on reported metrics guiding return to sport following ACLR. Evaluation of LSI when compared to the contralateral extremity is the most commonly reported functional measure, with ACL-RSI, IKDC and KOOS-QoL also being reported. Further investigations examining return to sport rate and the incidence of recurrent injury, factoring in differences in sex, competition level, and the presence or absence of concomitant meniscal injuries, based on functional metrics and PROMs is warranted to better understand which outcome measures are predictive of successful return to sport following ACLR.

Sex-based differences in physical and psychological recovery, and return to sport, following anterior cruciate ligament reconstruction

BACKGROUND

A robust comparison of the recovery pathway between sexes after anterior cruciate ligament reconstruction (ACLR) is lacking. This study investigated sex-based differences in physical and psychological recovery, and return to sport (RTS), after ACLR.

METHODS

104 community-level patients underwent ACLR. Patients were evaluated at 6-, 12- and 24-months with the Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI), International Knee Documentation Committee (IKDC) form and Tegner Activity Scale (TAS), a 4-hop test battery including the 6-meter timed hop (6MTH) and the single (SHD), triple (THD) and triple crossover (TCHD) hop tests for distance, and peak isokinetic knee extensor and flexor torque. Sex-based differences were assessed, while regression analysis modelled the relationship between patient characteristics and outcomes, with 24-month psychological readiness to RTS.

RESULTS

All PROMS improved (p < 0.05), with males reporting higher 24-month ACL-RSI (p = 0.002), IKDC (p = 0.007) and TAS (p = 0.005) scores. A greater percentage of males returned to pivoting sports at 24 months (p = 0.030, males 60.0%, females 40.8%). Males demonstrated higher knee extensor strength LSIs at 6 (p = 0.037) and 24 (p = 0.047) months, and higher knee flexor strength LSIs at 6 (p = 0.007) and 12 (p = 0.002) months. IKDC knee scores (β = 24.9; 95% CI, 10.8 to 35.0), male sex (β = 12.2; 95% CI, 3.9 to 20.4) and the 6MTH LSI (β = 1.31; 95% CI, 0.6 to 2.1) were associated with the ACL-RSI.

CONCLUSIONS

In community-level ACLR patients, females demonstrated lower physical performance recovery, subjective function and psychological readiness, as well as a lower rate of RTS.

Advanced Neuromuscular Training Differentially Changes Performance on Visuomotor Reaction Tests and Single-leg Hop Tests in Patients with ACL Reconstruction

Background

Advanced neuromuscular training prepares patients with anterior cruciate ligament reconstruction (ACLR) for sport participation. Return-to-sport testing often includes single-leg hop tests, yet combining motor and cognitive tasks (i.e., dual-task) might reveal neurocognitive reliance.

Purpose/Hypothesis

This study examined changes in performance on visuomotor reactions tests and single-leg hop tests following advanced neuromuscular training in patients with ACLR. The hypothesis was that performance would improve less on reaction tests than on single-leg hop tests.

Study Design

Quasi experimental, Pretest-Posttest.

Methods

Twenty-five patients with ACLR (11 males) completed 10 sessions of advanced neuromuscular training and pre-and post-training testing. Reaction tests outcomes were from a platform and visual display. The double-leg reaction test involved touching target dots with either leg for 20 seconds; correct touches and errors were recorded. The single-leg reaction test involved hopping on the test leg to 10 target dots; hop time and errors were recorded. Single-leg hop tests included forward, triple, crossover triple, and timed hop; limb symmetry index was recorded. Effect sizes were calculated for corrected touches on the double-leg reaction test, surgical side hop time on the single-leg reaction test, and surgical side hop distance or time on single-leg hop tests.

Results

Correct touches on the double-leg reaction test significantly increased from pre- to post-training (20.4 +/- 4.3 vs. 23.9 +/- 2.8, p<0.001). Hop time on the single-leg reaction test significantly decreased from pre- to post-training (Surgical leg 13.2 vs. 12.3 seconds, non-surgical leg 13.0 vs. 12.1 seconds, p=0.003). Mean errors did not significantly change on either reaction test (p> 0.05). Cohens d effect sizes in descending order was single-leg hop tests (d=0.9 to 1.3), double-leg reaction test (d=0.9), and single-leg reaction test (d=0.5).

Conclusion

Motor performance improved after advanced neuromuscular training, but the effect size was less on visuomotor reaction tests than single-leg hop tests. The results suggest persistence of neurocognitive reliance after ACLR and a need for more dual-task challenges in training.

Level of Evidence

3.

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.

Return to sports after an ACL reconstruction in 2024 - A glass half full? A narrative review

A successful return to sports (RTS) after an anterior cruciate ligament reconstruction (ACLR) is multifactorial, and therefore difficult and challenging. Unfortunately, low percentages of patients RTS, and for those who succeed, one-fifth of patients will sustain a second ACL injury. Over the past years, test batteries were developed to assess whether patients can RTS with a low risk for a second ACL injury risk. Low rates of patients who meet RTS criteria were found, coupled with the insufficiency of current RTS test batteries in predicting second ACL injuries suggesting poor sensitivity. The result of an RTS test is likely to reflect the content of a rehabilitation program, raising critical questions regarding what we are offering patients within the rehabilitation programme. Are we preparing our patients well enough for the high demands of complex situations within pivoting team sports? This narrative review offers insights from key lessons of the last 15 years on 1) RTS testing, 2) the content of rehabilitation, and 3) the RTS continuum, all from a "helicopter perspective".

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

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

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

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

Progressive submaximal effort hamstring muscle endurance is reduced after reconstruction of the anterior cruciate ligament

BACKGROUND

Endurance capability in the muscles controlling the knee is poorly understood post anterior cruciate ligament (ACL) reconstruction, despite many sporting activities requiring notable muscle endurance. The hamstring muscles, when active, provide important anatomical support to protect the reconstructed graft. In the absence of good hamstring endurance, fatigue may predispose individuals to re-injury.

OBJECTIVE

To assess whether ACL reconstruction (ACLR) with a hamstring graft leads to reduced hamstring endurance 9-13 months post-surgery.

STUDY DESIGN

A cross-sectional inter-limb comparison study was undertaken with participants 9-13 months after an ACLR with a hamstring graft, and a group of age, sex, and activity-matched controls. There were 22 participants in each group.

METHOD

Submaximal hamstring endurance was measured using a progressive fatigue test on an isokinetic dynamometer at a joint angular velocity of 120°/second. The dependant variable was the maximum number of repetitions performed. Statistical comparisons were made across injured, uninjured and control group limbs.

RESULTS

There was a significant (p < 0.05) deficit in hamstring endurance observed between the injured leg (mean: 111 repetitions, SD 49) and uninjured leg (mean: 136 repetitions, SD 67) of the ACL group, but not between the uninjured and control group legs (mean: 124 repetitions, SD 50).

CONCLUSION

The 18% deficit in submaximal hamstring endurance across the ACL-reconstructed individual's limbs is indicative of a notable loss in muscle performance at 9-13 months post-surgery. These results provide initial evidence for supporting further research examining the inclusion of hamstring endurance training in ACL rehabilitation programmes post-surgery.

The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction

CONTEXT

Anterior cruciate ligament (ACL) injuries greatly impact patients in terms of future performance, reduced physical activity and athletic participation, and overall economic burden. Decades of research have investigated how to improve ACL reconstruction (ACLR) outcomes. Recently, there has been growing interest to understand the effects of psychosocial factors on patient outcomes.

STUDY DESIGN

Clinical review.

EVIDENCE ACQUISITION

A search of the PubMed database was performed in March 2023. Articles were reviewed by at least 2 authors to determine relevance. We highlighted publications of the past 5 years while incorporating previous pertinent studies.

LEVEL OF EVIDENCE

Level 5.

RESULTS

There is no standardization of psychosocial factors regarding ACLR. As such, there is a lack of consensus regarding which psychosocial measures to use and when. There is a need for clarification of the complex relationship between psychosocial factors and physical function. Despite this, psychosocial factors have the potential to help predict patients who are more likely to return to sport: (1) desire/motivation to return; (2) lower levels of kinesiophobia; (3) higher levels of self-efficacy, confidence, and subjective knee function; (4) risk acceptance; and (5) social support. However, there are no standardized interventions to improve psychosocial factors after ACLR.

CONCLUSION

Psychosocial factors affect outcomes after ACLR. However, the interplay between psychosocial factors and physical function is complex. There is emerging evidence that testing and interventions may improve ACLR outcomes. There is a lack of standardized interventions to determine or improve psychosocial factors after ACLR. Further research is needed to identify psychosocial factors and to develop standardized interventions for clinicians to implement to improve clinical outcomes.

Hop to It! The Relationship Between Hop Tests and The Anterior Cruciate Ligament - Return to Sport Index After Anterior Cruciate Ligament Reconstruction in NCAA Division 1 Collegiate Athletes

Background

Outcomes after anterior cruciate ligament reconstruction (ACLR) may not be optimal, with poor physical and psychological function potentially affecting return to sport (RTS) ability. Understanding the relationship between commonly used hop tests and the Anterior Cruciate Ligament - Return to Sport Index (ACL-RSI) may improve rehabilitation strategies and optimize patient outcomes.

Hypothesis/Purpose

The purpose of this study was to examine the relationship between ACL-RSI scores and limb symmetry index (LSI) for the single hop for distance (SHD), triple hop for distance (THD), crossover hop for distance (CHD), timed 6-meter hop (T6H), and single leg vertical hop (SLVH) in a cohort of National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes after ACLR. The hypothesis was that SLVH LSI would be more highly correlated with ACL-RSI score than all horizontal hop tests.

Study design

Cross-Sectional Study.

Methods

Twenty-one National Collegiate Athletic Association (NCAA) Division 1 collegiate athletes (7 males, 14 females) at 6.62 ± 1.69 months after ACLR were included in this retrospective study. Primary outcomes were ACL-RSI score and LSI for SHD, THD, CHD, T6H, and SLVH. The relationship between ACL-RSI scores and performance on hop tests (LSIs) was evaluated using correlation analysis and step-wise linear regression (p ≤ 0.05).

Results

There were significant correlations found when comparing ACL-RSI and the LSI for SHD (rs = 0.704, p < 0.001), THD (rs = 0.617, p = 0.003), CHD (rs = 0.580, p = 0.006), and SLVH (rs = 0.582, p = 0.006). The CHD explained 66% (R2 value of 0.660) of the variance in the ACL-RSI, while the other hop tests did not add to the predictive model.

Conclusions

Physical function has the capacity to influence psychological status after ACLR. Clinicians should recognize that SLVH, SHD, THD, and CHD are correlated with ACL-RSI and improvements in physical function during rehabilitation may improve psychological status and optimize RTS after ACLR.

Level of evidence

Level 3.

Comparing the Effects of Differential and Visuo-Motor Training on Functional Performance, Biomechanical, and Psychological Factors in Athletes after ACL Reconstruction: A Randomized Controlled Trial

Variation during practice is widely accepted to be advantageous for motor learning and is, therefore, a valuable strategy to effectively reduce high-risk landing mechanics and prevent primary anterior cruciate ligament (ACL) injury. Few attempts have examined the specific effects of variable training in athletes who have undergone ACL reconstruction. Thereby, it is still unclear to what extent the variations in different sensor areas lead to different effects. Accordingly, we compared the effects of versatile movement variations (DL) with variations of movements with emphasis on disrupting visual information (VMT) in athletes who had undergone ACL reconstruction. Forty-five interceptive sports athletes after ACL reconstruction were randomly allocated to a DL group (n = 15), VT group (n = 15), or control group (n = 15). The primary outcome was functional performance (Triple Hop Test). The secondary outcomes included dynamic balance (Star Excursion Balance Test (SEBT)), biomechanics during single-leg drop-landing task hip flexion (HF), knee flexion (KF), ankle dorsiflexion (AD), knee valgus (KV), and vertical ground reaction force (VGRF), and kinesiophobia (Tampa Scale of Kinesiophobia (TSK)) assessed before and after the 8 weeks of interventions. Data were analyzed by means of 3 × 2 repeated measures ANOVA followed by post hoc comparison (Bonferroni) at the significance level of p ≤ 0.05. Significant group × time interaction effects, main effect of time, and main effect of group were found for the triple hop test and all eight directions, SEBT, HF, KF, AD, KV, VGRF, and TSK. There was no significant main effect of group in the HF and triple hop test. Additionally, significant differences in the triple hop test and the seven directions of SEBT, HF, KF, KV, VGRF, and TSK were found between the control group and the DL and VMT groups. Between group differences in AD and the medial direction of SEBT were not significant. Additionally, there were no significant differences between VMT and the control group in the triple hop test and HF variables. Both motor learning (DL and VMT) programs improved outcomes in patients after ACL reconstruction. The findings suggest that DL and VMT training programs lead to comparable improvements in rehabilitation.

Association Between Preoperative Multidimensional Psychological Distress and Physical Function After Surgery for Sports-Related Injury

Background

Psychological distress after orthopaedic surgery can lead to worse outcomes, including higher levels of disability and pain and lower quality of life. The 10-item Optimal Screening for Prediction for Referral and Outcome-Yellow Flag (OSPRO-YF) survey screens for multiple psychological constructs relevant to recovery from orthopaedic injury and may be useful to preoperatively identify patients who may require further psychological assessment and possible intervention after surgery.

Purpose/Hypothesis

To determine the association between the OSPRO-YF and physiological patient-reported outcomes (PROs). It was hypothesized that higher OSPRO-YF scores (indicating worse psychological distress) would be associated with worse PRO scores at time of return to sport.

Study Design

Case series; Level of evidence, 4.

Methods

This study evaluated 107 patients at a single, academic health center who were assessed at a sports orthopaedics clinic and ultimately treated surgically for injuries to the knee, shoulder, foot, or ankle. Preoperatively, patients completed the OSPRO-YF survey as well as the following PRO measures: Patient-Reported Outcomes Measurement Information System (PROMIS), Single Assessment Numeric Evaluation, numeric rating scale for pain; American Shoulder and Elbow Surgeons standardized shoulder assessment form for patients with shoulder injuries, the International Knee Documentation Committee score (for patients with knee injuries), and the Foot and Ankle Ability Measure (FAAM; for patients with foot or ankle injuries). At the time of anticipated full recovery and/or return to sport, patients again completed the same PRO surveys. Multivariable regression was used to evaluate the association between total OSPRO-YF score at baseline and PRO scores at the time of functional recovery.

Results

The baseline OSPRO-YF score predicted postoperative PROMIS Physical Function and FAAM Sports scores only. A 1-unit increase in the OSPRO-YF was associated with a 0.55-point reduction in PROMIS Physical Function (95% CI, -1.05 to -0.04; P = .033) indicating worse outcomes. Among patients who underwent ankle surgery, a 1-unit increase in OSPRO-YF was associated with a 6.45-point reduction in FAAM Sports (95% CI, -12.0 to -0.87; P = .023).

Conclusion

The study findings demonstrated that the OSPRO-YF survey predicts certain long-term PRO scores at the time of expected return to sport, independent of baseline scores.

Isometric Knee Strength is Greater in Individuals Who Score Higher on Psychological Readiness to Return to Sport After Primary Anterior Cruciate Ligament Reconstruction

Background

Anterior cruciate ligament (ACL) injury is extremely common among athletes. Rate of second ACL injury due to surgical graft rupture or contralateral limb ACL injury is approximately 15-32%. Psychological readiness to return to sport (RTS) may be an important predictor of successful RTS outcomes. Psychological readiness can be quantified using the ACL Return to Sport after Injury (ACL-RSI) questionnaire, with higher scores demonstrating greater psychological readiness.

Purpose

The purpose of this study was to investigate differences in functional performance and psychological readiness to return to sport among athletes who have undergone primary ACL reconstruction (ACLR).

Study Design

Descriptive cohort study.

Methods

Eighteen athletes who had undergone primary ACLR were tested at time of RTS clearance. The cohort was divided into two groups, high score (HS) and low score (LS), based on median ACL-RSI score, and performance on static and dynamic postural stability testing, lower extremity isokinetic and isometric strength testing, and single leg hop testing was compared between the groups using an independent samples t-test.

Results

The median ACL-RSI score was 74.17. The average ACL-RSI score was 83.1±6.2 for the HS group and 61.8±8.0 for the LS group. High scorers on the ACL-RSI performed significantly better on isometric knee flexion as measured via handheld dynamometry (22.61% ±6.01 vs. 12.12% ±4.88, p=0.001) than the low score group.

Conclusion

The findings suggest that increased knee flexion strength may be important for psychological readiness to RTS after primary ACLR. Further research is indicated to explore this relationship, however, a continued emphasis on improving hamstring strength may be appropriate during rehabilitation following ACLR to positively impact psychological readiness for RTS.

Level of Evidence

III.

Psychological readiness to return to sports practice and risk of recurrence: Case studies

Returning to sport after the sports injury is a difficult decision because it's multicausal and the fact that a rash decision can result in numerous negative consequences. Given the importance of psychological variables for the correct rehabilitation of the injured athlete and his or her optimal return to sports practice, there seems to be little information on this subject. In this sense, the objective is to determine the relationship between the subjective psychological disposition of the athlete in the process of Return to Play (RTP) with the type of mood profile and his mental health. This is based on the fact that each athlete evaluates his or her recovery differently and has different levels of anxiety, depression, and stress. For this purpose, four athletes participated in the study. Two males and two females from the sports of indoor soccer and soccer, who had just returned to sports after a moderate or severe injury. The average age was 24.25 years. Various measurements were taken after practices and after matches, to assess mood, psychological readiness, anxiety, stress, and depression. The results confirm Morgan's iceberg profile and the influence that subjective psychological perceptions and assessed emotional states have on athletes' incorporation into their sports practice with a guarantee of success.

A Systematic Review and Meta-Analysis of Strength Recovery Measured by Isokinetic Dynamometer Technology after Anterior Cruciate Ligament Reconstruction Using Quadriceps Tendon Autografts vs. Hamstring Tendon Autografts or Patellar Tendon Autografts

Background: This systematic review and meta-analysis compared the isokinetic strength of the muscular knee joint between quadriceps tendon autografts (QTAs) and hamstring tendon autografts (HTAs) or patellar tendon autografts (PTAs) after anterior cruciate ligament (ACL) reconstruction by determining the isokinetic angular velocity and follow-up time points. The functional outcomes and knee stability at the same time points were also compared using isokinetic technology. Methods: Two independent reviewers searched the Medline (via PubMed search engine), Scopus, Web of Science and Cochrane Library databases to include full text comparative studies that assessed isokinetic strength test following ACL reconstruction. The DerSimonian and Laird method was used. Results: In total, ten studies were included; seven compared studies QTAs vs. HTAs, and three compared QTAs vs. PTAs. Five studies were included in the meta-analysis. Isokinetic strength data were reported 3, 6, 12 and 24 months after ACL reconstruction. Conclusions: The QTAs showed better and significant results with knee flexion compared with HTAs, similar results to PTAs at 6 and 12 months. While HTAs showed better and significant results with knee extension at 6 months and similar results at 12 months compared to QTAs. Furthermore, a standardized isokinetic strength test must be followed to achieve a more specific conclusion and better clinical comparison among participants.

Selective bundle reconstruction for symptomatic partial anterior cruciate ligament tears demonstrates good functional scores, high return to sport rates and a low re-tear rate

BACKGROUND

The treatment of symptomatic partial anterior cruciate ligament (ACL) tears remains controversial. This study investigated the clinical and functional outcome of patients undergoing selective posterolateral (PLB) or anteromedial (AMB) bundle reconstruction.

METHODS

55 consecutive patients underwent partial bundle reconstruction, of which 45 (AMB = 17, PLB = 28) were included in the current analysis (62% male, mean age of 29.1 years). Patients were assessed at 12 and 24 months with patient-reported outcome measures (PROMs), graft laxity (KT-1000), knee extensor and flexor torque and a 4-hop battery. Limb Symmetry Indices (LSIs) were calculated. Return to sport (RTS) rates, re-operations and re-injuries were evaluated.

RESULTS

High scoring PROMs were evident, with 62% and 84% of patients participating in pivoting sports at 12 and 24 months, respectively. Overall, 98% of patients demonstrated 'normal' knee laxity at 24 months. Mean LSIs for all hop tests were ≥ 90% at 12 and 24 months, with 76-87% of patients demonstrating LSIs ≥ 90% on the four hop tests employed at 12 months, which was 89-93% of patients at 24 months. A mean knee extensor torque LSI of 89% and 97% was observed at 12 and 24 months. Two ipsilateral re-tears (2/55, 3.6%, AMB = 1, PLB = 1) were observed over the 24-month period, with no contralateral ACL tears.

CONCLUSIONS

High levels of physical function and RTS were observed in patients following partial bundle reconstruction, higher than that reported in the literature in patients undergoing ACLR, without evidence of instability and a low re-injury rate.

Have We Forgotten Our Patient? An Exploration of Patient Experiences After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Limited information is available on the experiences of patients during rehabilitation after anterior cruciate ligament reconstruction (ACLR).

AIM

The current study aimed to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR.

METHOD AND DESIGN

A survey-based study with an online platform was used to identify factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. Seventy-two patients (age 27.8 [8.8] y) after ACLR participated. Data were analyzed and themes were identified by comparing categories and subcategories on similarity.

MAIN FINDINGS

Positive patient experiences were room for own input, supervision, attention, knowledge, honesty, and professionalism of the physiotherapist. Additionally, a varied and structured rehabilitation program, adequate facilities, and contact with other patients were identified as positive patient experiences. Negative experiences were a lack of attention, lack of professionalism of the physiotherapists, a lack of sport-specific field training, a lack of goal setting, a lack of adequate facilities, and health insurance costs.

CONCLUSIONS

The current study identified factors that differentiated positive and negative patient experiences during rehabilitation after ACLR. These findings can help physiotherapists in understanding the patient experiences during rehabilitation after ACLR.

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

Background:

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

Hypothesis:

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

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

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

Results:

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

Conclusion:

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

Registration:

NCT02664545 (ClinicalTrials.gov identifier).

Arabic Version of the Short Anterior Cruciate Ligament-Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation

Background:

The short version of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) scale is a self-reported questionnaire developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR).

Purpose:

To translate, cross-culturally adapt, and validate the short version of the ACL-RSI scale into the Arabic language (ACL-RSI-Ar).

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

The original short version of the ACL-RSI scale was forward and backward translated, cross-culturally adapted, and validated following international standardized guidelines. Sixty patients who participated in sports activities and underwent ACLR completed the ACL-RSI-Ar, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and Knee injury and Osteoarthritis Outcome Score (KOOS) scales. To assess test-retest reliability, 34 participants completed the ACL-RSI-Ar scale twice. Statistical tests were conducted to test the internal consistency, reliability, and construct and discriminant validity of the ACL-RSI-Ar scale.

Results:

The ACL-RSI-Ar showed adequate internal consistency (Cronbach alpha = 0.734) and excellent test-retest reliability (intraclass correlation coefficient, 0.871). The ACL-RSI-Ar was strongly correlated with the IKDC (Spearman ρ = 0.515, P < .001) and weakly to strongly correlated with all KOOS subscales (Spearman ρ = 0.247-0.590, P < .05). Patients who returned to sports had significantly higher scores on the ACL-RSI-Ar scale when compared with those who did not return to sports (P = .001).

Conclusion:

The short ACL-RSI-Ar scale, as translated, was internally consistent, reliable, and valid for evaluating psychological readiness to return to sports after ACLR in Arabic-speaking patients.

Advanced training enhances readiness to return to sport after anterior cruciate ligament reconstruction

Patients with anterior cruciate ligament reconstruction (ACLR) are often psychologically and physically under-prepared for sports participation. This study compared readiness to return to sport based on completion of advanced training after ACLR. Patients with ACLR who self-selected participation in a 6-week group-format advanced training program (TRAINING) were compared to age- and sex-matched patients who did not participate (NoTRAINING). Each group had 23 participants (14 females). Advanced training consisted of plyometric, strengthening, and agility exercises. Baseline and follow-up testing included psychological measures (Anterior Cruciate Ligament Return to Sport after Injury [ACL-RSI]; Tampa Scale for Kinesiophobia [TSK-11]; Knee Activity Self-Efficacy [KASE]; and fear intensity for the primary fear-evoking task or situation) and a hop test battery. Return to sport criteria were ACL-RSI score ≥70 points and limb symmetry index ≥90% on all hop tests. At follow-up, KASE score was higher in TRAINING than NoTRAINING (92.7 vs. 89.1 points; respectively), but ACL-RSI, TSK-11 and fear intensity scores were not significantly different between groups. Return to sport criteria passing rate was not significantly different between groups at baseline (TRAINING: 13%, NoTRAINING: 30%) or follow-up (TRAINING: 52%, NoTRAINING: 43%); however, the distribution of criteria met at follow-up differed with more patients in TRAINING than NoTRAINING meeting hop test criteria (30% vs. 4%, respectively) and more patients in NoTRAINING than TRAINING failing to meet any criteria (25% vs. 0%, respectively). Advanced training after ACLR facilitated readiness for sport participation by improving confidence and hop performance, but may not have a preferential effect on fear.

Perceived Social Support, Reinjury Anxiety, and Psychological Readiness to Return to Sport in Soccer Players

The burden of sports injury in soccer is high, and return to sport outcomes following injury are often poor. This is compounded by a current lack of understanding surrounding the factors that may optimize psychological readiness to return to sport. Consequently, in the present study, we aim to further our understanding of these issues by examining the role of perceived social support in predicting psychological readiness to return to sport. In doing so, we extend previous research by examining whether reinjury anxiety is a mediating factor in this relationship. A sample of 150 previously injured soccer players (mean age = 25.32 y) completed measures of perceived social support, reinjury anxiety during rehabilitation, and psychological readiness to return to sport. Mediation analyses showed that reinjury anxiety partly accounted for the positive relationship between perceived social support and psychological readiness to return to sport. These findings suggest that injured soccer players with higher perceptions of social support will experience less reinjury anxiety during rehabilitation and, as a consequence, will be more psychologically ready upon return to sport.

Confidence, ability to meet return to sport criteria, and second ACL injury risk associations after ACL-reconstruction

This study tested the hypotheses that participants with high knee-related confidence at the time of return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction (ACLR) would have a greater likelihood of meeting RTS criteria and would have a higher likelihood of second ACL injury. Participants completed RTS testing when cleared to RTS. Success was defined as an IKDC score more than or equal to 90 and all limb symmetry index (LSI) scores more than or equal to 90%. Confidence groups were created based on response to the KOOS Quality of Life subscale. Incidence of second ACL injury was tracked for 24 months after RTS. Associations among confidence, success in meeting RTS criteria, and second ACL injury were evaluated. At RTS, 37.7% were classified with high knee-related confidence, 26.4% met RTS criteria and 22.0% sustained a second ACL injury post-RTS. A higher proportion of confident participants met all RTS criteria (p = 0.001). Confident participants were over two times more likely to suffer a second ACL injury (odds ratio [OR] = 2.40; 95% confidence interval [CI]:1.21-5.20) (p = 0.02) and participants who were both confident and met all RTS criteria were 10 times more likely to suffer a second ACL injury (OR = 9.6; 95% CI:1.1, 84.2) (p = 0.02) than those who passed all RTS criteria but lacked knee-related confidence. Clinical significance: Confident, young athletes at the time of RTS after ACLR are more likely to meet all RTS criteria and more likely to sustain a second ACL injury after RTS. Future work must consider how the inclusion of additional factors into RTS criteria may better identify those at high risk for poor outcome after ACLR.

ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians' current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice.

EVIDENCE ACQUISITION

Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey-Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline.

CONCLUSION

Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport.

STRENGTH OF RECOMMENDATION TAXONOMY (SORT)

B.

Assessing implementation, limited efficacy, and acceptability of the BEAST tool: A rehabilitation and return-to-sport decision tool for nonprofessional athletes with anterior cruciate ligament reconstruction

OBJECTIVES

To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool - a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes.

DESIGN

Prospective cohort.

PARTICIPANTS

43 nonprofessional pivoting sport athletes with ACLR.

MAIN OUTCOME

Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes' beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability).

RESULTS

The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely).

CONCLUSION

The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

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

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

LEVEL OF EVIDENCE

5.

The psychological readiness to return to sports of patients with anterior cruciate ligament reconstruction preoperatively and 6 months postoperatively

OBJECTIVE

To determine the association of psychological readiness to return to sports preoperative and 6 months post-reconstruction in athletes with anterior cruciate ligament (ACL) injury.

DESIGN

Retrospective cohort study.

SETTING

Clinical center of sports medicine.

PARTICIPANTS

Fifty athletes, aged 16-45 years, were included in this study. Participants had a modified Tegner activity scale score ≥5 before ACL injury.

MAIN OUTCOME MEASURES

Participants were divided into High and Low groups based on ACL-return to sport after injury scale (ACL-RSI) scores 6 months post-ACL reconstruction (ACLR) (cutoff: 56 points).

RESULTS

The Low group had lower ACL-RSI scores than the High group preoperatively (P < 0.001) and 6 months post-ACLR (P < 0.001). The High group had a significantly greater amount of change in ACL-RSI scores preoperatively to 6 months post-ACLR than the Low group (P = 0.003). Preoperative ACL-RSI scores increased significantly to 6 months post-ACLR in the entire group of participants (P < 0.001) and in the High group (P < 0.001). However, in the Low group, ACL-RSI scores did not increase significantly (P = 0.714).

CONCLUSIONS

Participants with low ACL-RSI scores 6 months post-ACLR had low preoperative ACL-RSI scores that did not improve preoperatively to 6 months post-ACLR.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

OBJECTIVES

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making.

METHODS

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

RESULTS

Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.

CONCLUSION

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.

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

OBJECTIVES

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

DESIGN

Survey-based study.

SETTING

Online survey platform.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Outcome Measures After Shoulder Stabilization in the Athletic Population: A Systematic Review of Clinical and Patient-Reported Metrics

Background:

Athletic endeavor can require the “athletic shoulder” to tolerate significant load through supraphysiological range and often under considerable repetition. Outcome measures are valuable when determining an athlete’s safe return to sport. Few data are available to guide a clinician’s choice from the variety of measures available.

Purpose:

To describe the use of quantifiable objective outcome measures and patient-reported outcome tools after glenohumeral joint stabilization, specifically in an athletic population. The secondary aim of our study was to assess whether the method of measurement used was clearly described and standardized to aid clinical interpretation.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

A systematic search of MEDLINE, Scopus, SPORTDiscus, and Web of Science databases was performed in December 2018 based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the application of selection criteria, a full review of identified papers, and screening of reference lists, a total of 62 studies were included in the review. All studies were independently appraised for quality, predefined data fields were populated and cross-checked for accuracy, and results were then summarized from these data fields.

Results:

Of the 62 included studies, 94% used a quantifiable objective clinical outcome. A majority (85%) of the studies measured range of motion, 21% recorded muscle strength, 5% measured electromyographic activity, 5% examined shoulder kinematics, and 3% assessed joint proprioception after surgery. However, only 18% of the studies clearly described a standardized method of measuring the outcome. Nearly all (95%) of the studies used at least 1 patient-reported outcome measure. The Rowe score was most commonly used (35%).

Conclusion:

We must standardize and clearly describe the use of quantifiable objective outcome measures to aid clinical interpretation. A concerted effort should also be made to standardize the use of patient-reported outcome tools after shoulder stabilization in the athletic population.

Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group

PURPOSE

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS and description of the RTS continuum, as well as to provide clinical guidance on RTS testing and decision-making.

METHODS

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

RESULTS

Key points include that RTS is characterized by achievement of the pre-injury level of sport and involves a criteria-based progression from return to participation to return to sport, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along a RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.

CONCLUSION

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biologic assessment of healing and recovery.

LEVEL OF EVIDENCE

IV.

Return to Sport After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Return to Sport Consensus Group

Background

A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sport and their previous activity level.

Purpose

The aim of the Panther Symposium ACL Injury Return to Sport Consensus Group was to provide a clear definition of RTS after ACL injury and a description of the RTS continuum as well as provide clinical guidance on RTS testing and decision-making.

Study Design

Consensus statement.

Methods

An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.

Results

Key points include that RTS is characterized by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS and, ultimately, return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum, with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors, and concomitant injuries.

Conclusion

The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing, and methods for the biological assessment of healing and recovery.

Injury-Related Fears During the Return-to-Sport Phase of ACL Reconstruction Rehabilitation

Background:

Fear of reinjury is common after anterior cruciate ligament reconstruction (ACLR) and often deters a return to preinjury sport participation. A better understanding of injury-related fear is needed to inform rehabilitation strategies.

Purpose/Hypothesis:

The purpose of this study was to (1) identify individual fear-evoking tasks or situations, (2) compare the intensity and amount of change relative to other injury-related fears (reinjury, knee giving way, and knee pain) after completion of a return-to-sport training program, and (3) determine whether standardized questionnaires can identify the intensity of fear for the individual fear-evoking task or situation and for fear of reinjury. The hypothesis was that the task or situation that evokes fear would vary across patients and the intensity of that fear would be higher and show less change after return-to-sport training compared with other injury-related fears.

Study Design:

Case series; Level of evidence, 4.

Methods:

Participants included 33 patients (15 males; mean age, 18 years) with ACLR who enrolled in a group-format return-to-sport training program. Questionnaires completed before and after return-to-sport training included items to specify fear-evoking tasks or situations, items to rate the intensity of various injury-related fears, the Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI), and the Tampa Scale for Kinesiophobia (TSK-11).

Results:

The most common fear-evoking task or situation was cutting, followed by contact, jumping, and other. Intensity of fear-evoking task or situation was higher than other injury-related fears, but all fears decreased in intensity after training. The ACL-RSI score better identified the intensity of fear for the individual fear-evoking task or situation and for fear of reinjury than did the TSK-11 score.

Conclusion:

Activities that evoke fear vary across patients, but fear of cutting is common. The intensity of common fears after ACLR decreased after advanced group training, and large effect sizes were seen for nearly all examined fears. Fear of reinjury and intensity of individually feared tasks may be better reflected in the ACL-RSI score than the TSK-11 score.