Clinical Outcome Measures and Return-to-Sport Timing in Adolescent Athletes After Anterior Cruciate Ligament Reconstruction

Lower extremity return to sport testing: A systematic review

BACKGROUND

Lower extremity injuries account for an enormous portion of sports medicine cases in the United States each year. Unfortunately, there are no uniform criteria for athletes to complete prior to returning to sport (RTS) following a lower extremity injury. Therefore, the purpose of this systematic review is to review current literature for joint-specific and global lower extremity testing to determine the most valid functional test that can be utilized to reduce the risk of re-injury as athletes RTS.

METHODS

A systematic search of PubMed, PubMed Central, Cochrane Library, OVID, and Embase databases was conducted for studies prior to May 2024 following PRISMA guidelines. ROBINS-I Tool was utilized for the risk of bias assessment.

RESULTS

Of 19,189 studies, 114 (0.6%) studies published prior to May of 2024 met inclusion criteria and were analyzed. Eighty five percent of articles discussed RTS for individuals with knee pathology. Furthermore, 82% specifically analyzed RTS following ACL reconstruction. The most common RTS test was isokinetic dynamometry testing which is seen in 73% of studies. Only 6.2% of studies analyzed RTS for individuals with hip pathology and only two studies analyzed RTS for patients with ankle injuries.

CONCLUSION

Even with the enormous amount of literature that exists regarding ACL injuries and testing there is no standardized criterion for RTS clearance. The suggested test batteries from this review can serve as a framework for future research and validation for joint-specific RTS functional testing.

Return to training in soccer players after anterior cruciate ligament reconstruction: reflections and considerations

This clinical and rehabilitative overview focuses on the return to unrestricted sporting activity, aiming to consolidate the scientific evidence surrounding the structural progression of athletes, particularly footballers, undergoing anterior cruciate ligament reconstruction (ACLR). A multidisciplinary approach necessitates a shared language and standardized methodologies. Unfortunately, significant disparities persist in the structural strategies guiding the decision-making process for returning to on-field activities, the latter stages of rehabilitation, and subsequent restoration of technical and tactical football abilities. Divergences in definitions, terminologies, and rehabilitation protocols can substantially influence final outcomes. Presently, scientific consensus studies regarding the decision-making process during the final stages of on-field rehabilitation are lacking. Nevertheless, this overview outlines and defines pivotal language parameters crucial for effective communication and the seamless integration of clinical and rehabilitative data among the diverse professionals involved in facilitating the athlete's return to peak performance. In conclusion, the successful resumption of competitive sporting activities for footballer's post ACLR demands a collaborative decision-making approach encompassing various professionals. Additionally, it necessitates a cohesive transition from rehabilitation to on-field work, aiming at reinstating athleticism, technical prowess, and tactical acumen.

The effect of factors from different time points on psychological readiness following ACL reconstruction

OBJECTIVE

The purpose of this study was to examine factors correlated with psychological readiness to return to activity after ACLR.

DESIGN

cross sectional study.

SETTING

controlled laboratory.

PARTICIPANTS

164 patients (82 M/82 F, 22.5 ± 8.9yr, 171.6 ± 11.0 cm, 77.4 ± 18.6 kg, 8.6 ± 3.4 months post-ACLR) participated in this study after a primary, isolated, and uncomplicated ACLR.

MAIN OUTCOME MEASURES

ACL Return to Sport Index (ACL-RSI).

RESULTS

ACL-RSI scores demonstrated a weak positive correlation with activity level at the time of injury and a fair positive correlation with activity level at the time of post-operative testing (p-values: 0.004, <0.001). ACL-RSI scores showed a statistically significant fair negative correlation with pain and a moderate negative correlation with kinesiophobia during rehabilitation (p-values: <0.001, <0.001). There was no statistical significance between ACL-RSI and the surgical variables (p-value range: 0.10-0.61).

CONCLUSIONS

Outcomes from testing during postoperative rehabilitation were most correlated with psychological readiness to return to activity after ACLR. Increased pain and kinesiophobia were associated with a decreased psychological readiness. Increased activity level prior to injury and activity level at the time of testing during rehabilitation were both correlated with increased psychological readiness. Psychological readiness to return to activity may need to be customized based on potentially modifiable patient-specific factors during the post-operative rehabilitation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

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

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

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

The Influence of 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.

Which Tests Predict 6-Month Isokinetic Quadriceps Strength After ACL Reconstruction? An Examination of Isometric Quadriceps Strength and Functional Tests at 3 Months

Background

Restoration of quadriceps strength after anterior ligament reconstruction (ACLR) is a persistent challenge for patients and clinicians. Inadequate recovery of quadriceps strength has been linked to increase risk of re-injury. Developing methods of early identification of strength deficits is essential to allow clinicians to provide more individualized interventions early in the rehabilitation process.

Purpose

To determine whether 3-month isometric quadriceps strength, the Y-Balance Test (YBT), and the anterior step-down test are predictive of isokinetic quadriceps strength at six months in adolescents after ACLR.

Design

Retrospective cohort.

Methods

Thirty-six adolescent patients with primary ACLR (58% female, 36% with concomitant meniscal repair, age: 15.7 ± 1.6 years). At three months post-operative, isometric quadriceps strength via isokinetic dynamometer, YBT-Lower Quarter, and anterior step-down tests were completed. At six months post-operative, an isokinetic knee strength assessment was completed. Regression analysis was used to evaluate the predictive relationship between 3-month isometric tests and 6-month isokinetic knee extension tests.

Results

Three-month post operative isometric quadriceps peak torque predicted isokinetic quadriceps peak torque at 6 months, F(1,34) = 19.61, p <0.001. Three-month isometric quadriceps peak torque accounted for 36.6% of the variance in normalized isokinetic quadriceps peak torque at 6 months with adjusted R2 = 34.7%. Including YBT anterior reach (β = 0.157, p = 0.318) in regression added 1.9% of variance when predicting 6-month isokinetic quadriceps peak torque, F (2,33) = 10.32, p <0.001, R2 = 0.385, ΔR2 = 0.019.

Conclusion

At three months post-ACLR, isometric strength testing appears more optimal than other functional tests in predicting isokinetic quadriceps peak torque in later stages of rehabilitation for adolescents. Clinicians should use tests at three months that measure quadriceps strength if aiming to predict isokinetic quadriceps peak torque at six months post-ACLR, rather than using functional tests such as the YBT-LQ or anterior step-down.

Level of Evidence

Level 3.

Early- and Late-Stage Benefits of Blood Flow Restriction Training on Knee Strength in Adolescents After Anterior Cruciate Ligament Reconstruction

Background

Blood flow restriction training (BFRT) after anterior cruciate ligament reconstruction (ACLR) is rising in popularity because of its benefits in reducing muscle atrophy and mitigating knee strength deficits.

Purpose

To investigate the impact BFRT has on adolescent knee strength after ACLR at 2 postoperative time points: at 3 months and the time of return to sport (RTS).

Study Design

Cohort study; Level of evidence, 3.

Methods

A prospective intervention (BFRT) group was compared to an age-, sex-, and body mass index-matched retrospective control group. Patients aged 12 to 18 years who underwent primary ACLR with a quadriceps tendon autograft were included. Along with a traditional rehabilitation protocol, the BFRT group completed a standardized BFRT protocol (3 BFRT exercises performed twice weekly for the initial 12 weeks postoperatively). Peak torque values for isometric knee extension and flexion strength (at 3 months and RTS) and isokinetic strength at 180 deg/s (at RTS) as well as Pediatric International Knee Documentation Committee (Pedi-IKDC) scores were collected. Differences between the BFRT and control groups were compared with 2-way mixed analysis of variance and 1-way analysis of variance.

Results

The BFRT group consisted of 16 patients (10 female; mean age, 14.84 ± 1.6 years) who were matched to 16 patients in the control group (10 female; mean age, 15.35 ± 1.3 years). Regardless of the time point, the BFRT group demonstrated significantly higher isometric knee extension torque compared to the control group (2.15 ± 0.12 N·m/kg [95% CI, 1.90-2.39] vs 1.74 ± 0.12 N·m/kg [95% CI, 1.49-1.98], respectively; mean difference, 0.403 N·m/kg; P = .024). The BFRT group also reported significantly better Pedi-IKDC scores compared to the control group at both 3 months (68.91 ± 9.68 vs 66.39 ± 12.18, respectively) and RTS (89.42 ± 7.94 vs 72.79 ± 22.81, respectively) (P = .047).

Conclusion

In adolescents, the addition of a standardized BFRT protocol to a traditional rehabilitation protocol after ACLR significantly improved knee strength and patient-reported function compared to a traditional rehabilitation program alone.

Reconsideration of Return-to-Sport Decision-Making After Pediatric ACL Injury: A Scoping Review

CONTEXT

Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%.

OBJECTIVES

(1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes.

DATA SOURCES

PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature.

STUDY SELECTION

Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies.

STUDY DESIGN

Scoping review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart.

RESULTS

Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported.

CONCLUSION

RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.

Post-operative rehabilitation following traumatic anterior shoulder dislocation: A systematic scoping review

Background

This systematic scoping review aimed to describe the content of post-operative rehabilitation programmes, and outcome measures selection following stabilisation surgery for traumatic anterior shoulder dislocation (TASD).

Methods

An electronic search of Medline, EMBASE, CINAHL and AMED was conducted (2000-2021). Any cohort or clinical trial of patients receiving post-operative TASD rehabilitation were included. Study selection, data extraction and quality appraisal were undertaken by two independent reviewers.

Results

Twelve studies including fourteen treatment programmes were eligible. Period of post-operative immobilisation ranged from 1 day to 6 weeks, with exercise introduced between 1 and 7 weeks. Strengthening exercises were introduced between 1 and 12 weeks. Two studies described "accelerated" rehabilitation programmes, differing in immobilisation period and exercise milestones. No increased recurrence was reported in professional footballers. Two studies compared rehabilitation programmes, one not randomised, the other 18 years old. There was variability in selected outcomes measures, with only 4 studies using a common measure.

Discussion

There is minimal evidence to guide post-operative rehabilitation, variability in immobilisation periods and when exercise is introduced. There is no consensus on the definition of accelerated rehabilitation, or outcome measure selection. Clinical consensus of standardised terminology and stages of rehabilitation is required prior to efficacy studies.

Association of Psychological Readiness to Return to Sports With Subjective Level of Return at 12 Months After ACL Reconstruction

Background

Return-to-sports (RTS) rates after anterior cruciate ligament (ACL) reconstruction (ACLR) differ according to the level at which patients return. It is unclear whether the level of RTS is affected by psychological readiness to return.

Purpose

To examine the association between psychological readiness to RTS and subjective RTS level 12 months after ACLR.

Study Design

Case-control study; Level of evidence, 3.

Methods

A total of 47 patients who underwent unilateral primary ACLR surgery were enrolled. Assessments at 6 and 12 months postoperatively consisted of knee strength testing (isokinetic quadriceps and hamstring strength), the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC-SKF), and the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale to measure psychological readiness to RTS. Patients were assigned to 1 of 3 subgroups based on their subjective assessment of RTS level at 12 months postoperatively: RTS at or above preinjury level (RTS≥Pre; n = 19), RTS below preinjury level (RTS

Results

Significant differences were found among the RTS≥Pre, RTS

Conclusion

The ACL-RSI score was significantly different among the study groups, and the ACL-RSI score at 12 months postoperatively and younger age were associated with RTS at or above preinjury level.

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Key Words

• ACL-RSI
• knee strength
• patient-reported knee function
• performance

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MESH Headings Collapse

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Affiliation(s)

Makoto Suzuki Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Tomoya Ishida Faculty of Health Sciences, Hokkaido University, Sapporo, Japan Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Hisashi Matsumoto Department of Rehabilitation, Hokushin Orthopaedic Hospital, Sapporo, Japan
Satoru Kaneko Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Chiharu Inoue Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Yoshimitsu Aoki Department of Orthopaedic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
Harukazu Tohyama Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
Mina Samukawa Faculty of Health Sciences, Hokkaido University, Sapporo, Japan

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Association Between Knee Extension Strength at 3 and 6 Months After Anterior Cruciate Ligament Reconstruction

CONTEXT

Deficits in knee extension strength after anterior cruciate ligament reconstruction have been a major problem. The inadequate recovery of the knee extension strength of surgical limb reportedly delays return to sports and increases reinjury risk. Accordingly, the early detection of knee extension strength deficits after reconstruction may help plan early interventions to manage impairment. This study aimed to clarify the association between knee extension strength at 3 and 6 months after anterior cruciate ligament reconstruction.

DESIGN

Retrospective study.

METHODS

Fifty patients who underwent primary anterior cruciate ligament reconstruction using hamstring grafts were included. At 3 months postoperatively, the limb symmetry index (LSI) of isokinetic knee extension strength (IKE) at 60°/s, degree of swelling, passive range of motion of knee flexion and extension, and anterior leg reach distance were measured. At 6 months postoperatively, the LSI of IKE was measured at 60°/s, which was used as the main outcome. A correlation analysis was performed with the LSI of IKE at 6 months postoperatively as the dependent variable and the LSI of IKE at 3 months postoperatively as the independent variable. Subsequently, a multiple regression analysis was performed, with LSI of IKE at 6 months postoperatively as the dependent variable; LSI of IKE at 3 months postoperatively as the independent variable; and other variables, demographic information, and surgical data as covariates.

RESULTS

The correlation analysis revealed that the LSIs of IKE at 3 and 6 months postoperatively were correlated (r = .535, P < .001). In the multiple regression analysis, the LSI of IKE at 3 months postoperatively was significantly associated with that at 6 months postoperatively, even when other variables were included as covariates (R2 = .349, P = .004).

CONCLUSION

Asymmetry of knee extension strength at 3 months postoperatively could be more useful than other variables related to knee strength in predicting the asymmetry of knee extension strength at 6 months postoperatively.

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.

Return to sport soccer after anterior cruciate ligament reconstruction: ISAKOS consensus

INTRODUCTION

Many factors can affect the return to pivoting sports, after an Anterior Cruciate Ligament Reconstruction. Prehabilitation, rehabilitation, surgical and psychological aspects play an essential role in the decision to return to sports. The purpose of this study is to reach an international consensus about the best conditions for returning to sports in soccer-one of the most demanding level I pivoting sports after anterior cruciate ligament (ACL) reconstruction.

METHODS

34 International experts in the management of ACL injuries, representing all the Continents were convened and participated in a process based on the Delphi method to achieve a consensus. 37 statements related to ACL reconstruction were reviewed by the experts in three rounds of surveys in complete anonymity. The statements were prepared by the working group based on previous literature or systematic reviews. Rating agreement through a Likert Scale: strongly agree, agree, neither agree or disagree, disagree and strongly disagree was used. To define consensus, it was established that the assertions should achieve a 75% of agreement or disagreement.

RESULTS

Of the 37 statements, 10 achieved unanimous consensus, 18 non-unanimous consensus and 9 did not achieve consensus. In the preoperative, the correction of the range of motion deficit, the previous high level of participation in sports and a better knowledge of the injury by the patient and compliance to participate in Rehabilitation were the statements that reached unanimous consensus. During the surgery, the treatment of associated injuries, as well as the use of autografts, and the addition of a lateral extra-articular tenodesis in some particular cases (active young athletes, <25 years old, hyperlaxity, high rotatory laxity and revision cases) obtained also 100% consensus. In the postoperative period, psychological readiness and its validation with scales, adequate physical preparation, as well as not basing the RTSS purely on the time of evolution after surgery, were the factors that reached unanimous Consensus.

CONCLUSIONS

The consensus statements derived from this international ISAKOS leaders, may assist clinicians in deciding when to return to sports soccer in patients after an ACL reconstruction. Those statements that reached 100% consensus have to be strongly considered in the final decision to RTS soccer.

Measurement properties for muscle strength tests following anterior cruciate ligament and/or meniscus injury: What tests to use and where do we need to go? A systematic review with meta-analyses for the OPTIKNEE consensus

Objectives

Critically appraise and summarise the measurement properties of knee muscle strength tests after anterior cruciate ligament (ACL) and/or meniscus injury using the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias checklist.

Design

Systematic review with meta-analyses. The modified Grading of Recommendations Assessment, Development and Evaluation-guided assessment of evidence quality.

Data sources

Medline, Embase, CINAHL and SPORTSDiscus searched from inception to 5 May 2022.

Eligibility criteria for selecting studies

Studies evaluating knee extensor or flexor strength test reliability, measurement error, validity, responsiveness or interpretability in individuals with ACL and/or meniscus injuries with a mean injury age of ≤30 years.

Results

Thirty-six studies were included involving 31 different muscle strength tests (mode and equipment) in individuals following an ACL injury and/or an isolated meniscus injury. Strength tests were assessed for reliability (n=8), measurement error (n=7), construct validity (n=27) and criterion validity (n=7). Isokinetic concentric extensor and flexor strength tests were the best rated with sufficient intrarater reliability (very low evidence quality) and construct validity (moderate evidence quality). Isotonic extensor and flexor strength tests showed sufficient criterion validity, while isometric extensor strength tests had insufficient construct and criterion validity (high evidence quality).

Conclusion

Knee extensor and flexor strength tests of individuals with ACL and/or meniscus injury lack evidence supporting their measurement properties. There is an urgent need for high-quality studies on these measurement properties. Until then, isokinetic concentric strength tests are most recommended, with isotonic strength tests a good alternative.

Short-Term Clinical Outcomes After Anterior Cruciate Ligament Reconstruction In Adolescents During The COVID-19 Pandemic

Background/Purpose

The COVID-19 pandemic has impacted adolescents across multiple areas of health. While many factors influence outcomes following anterior cruciate ligament reconstruction (ACLR), the impact of the COVID-19 pandemic on early patient outcomes after ACLR is currently unknown in an adolescent population. The purpose of this study was to determine if short-term clinical outcomes were different in adolescents after ACLR for those who underwent surgery pre-COVID versus during the COVID-19 pandemic timeframe.

Design

Retrospective cohort.

Methods

A retrospective review of records occurred for patients who underwent ACLR with a quadriceps tendon autograft. Two separate review timeframes were defined according to date of surgery (control: September 2017 - October 2019; COVID: March 2020 - May 2021). Patients were classified into pre-COVID (control) and COVID groups by surgical date and were then age- and sex-matched. Three-month postoperative outcomes were included for analysis, including normalized isometric quadriceps and hamstring peak torque, Anterior Cruciate Ligament - Return to Sport after Injury (ACL-RSI), and the Pedi International Knee Documentation Committee Form (Pedi-IKDC) scores.

Results

Sixty patients met the inclusion criteria (34 females, 56.7%). Follow-up testing occurred at 3.2 months (98.13 ± 14.91 days) postoperative. A significant difference was found between groups for normalized quadriceps peak torque on the uninvolved limb, with the control group (2.03 ± 0.47 Nm/kg) demonstrating decreased peak torque compared to the COVID group (2.49 ± 0.61 Nm/kg) (p =0.002, effect size (d) = 0.84). For the involved limb, no difference in normalized quadriceps peak torque was observed between the control group (1.25 ± 0.33 Nm/kg) and those who underwent surgery during the COVID-19 pandemic (1.49 ± 0.70 Nm/kg) (p = 0.09). No differences were identified between groups for any of the other strength outcomes (p = 0.31 - 0.87). Similarly, no differences in patient reported outcomes were found for Pedi-IKDC or ACL-RSI between groups (p = 0.12 - 0.43).

Conclusion

At roughly three months after ACLR, normalized quadriceps peak torque on the uninvolved limb was reduced by 18.5% for adolescents who underwent surgery pre-COVID versus during the COVID-19 pandemic timeframe. No group differences were observed for other isometric strength outcomes, Pedi-IKDC, or ACL-RSI scores.

Pediatric Revision Anterior Cruciate Ligament Reconstruction: Current Concepts Review

OBJECTIVE

We present a review of revision anterior cruciate ligament (ACL) reconstruction in pediatric patients, discussing risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes.

DATA SOURCES

PubMed, Cochrane, and Embase databases were queried for relevant articles about revision ACL topics. All types of manuscripts, including clinical studies, basic science studies, case series, current concepts reviews, and systematic reviews were analyzed for relevant information. Current concepts on risk factors for rerupture, physical examination and imaging, treatment principles and surgical techniques, postoperative rehabilitation, and clinical outcomes were synthesized.

MAIN RESULTS

Surgical treatment should be individualized, and the graft type, fixation devices, tunnel placement, and complementary procedures (eg, extra-articular tenodesis) should be tailored to the patient's needs and previous surgeries. Rehabilitation programs should also be centered around eccentric strengthening, isometric quadriceps strengthening, active flexion range of motion of the knee, and an emphasis on closed chain exercises. Despite adherence to strict surgical and postoperative rehabilitation principles, graft refailure rate is high, and return to sports rate is low.

CONCLUSION

Rerupture of the ACL in the pediatric population is a challenging complication that requires special attention. Diagnostic evaluation of repeat ACL ruptures is similar to primary injuries. Although outcomes after revision ACL reconstruction are expectedly worse than after primary reconstruction, athletes do return to sport after proper rehabilitation. Further research is needed to continue to improve outcomes in this high-risk population, aimed at continued knee stability, graft survivorship, and improved quality of life.

Male and Female Adolescent Athletes' Readiness to Return to Sport After Anterior Cruciate Ligament Injury and Reconstruction

OBJECTIVE

The purpose of this study was to examine whether readiness to return to sport (RTS) differed between adolescent male and female athletes after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Longitudinal, prospective cohort.

SETTING

Outpatient office associated with tertiary-care hospital.

PATIENTS

A total of 93 adolescent athletes, 17 years of age and younger, who underwent ACLR surgery with a hamstring autograft were included.

INDEPENDENT VARIABLES

Male and female athletes.

MAIN OUTCOME MEASURES

Anterior cruciate ligament-return to sport after injury (ACL-RSI) completed at 3 time points: (1) preoperatively (Pre-op), (2) approximately 3 months into rehabilitation (Post-op 1), and (3) during RTS phases of recovery (Post-op 2).

RESULTS

There was a significant main effect for both sex (P < 0.010) and time (P < 0.0001) with male athletes having higher ACL-RSI scores than female athletes at all 3 time points; however, there was no significant time by sex interaction. All ACL-RSI scores increased significantly across time, regardless of sex. There were no statistically significant differences between ACL-RSI scores at all 3 time points between individuals who did and did not receive physician clearance.

CONCLUSIONS

This study provides a longitudinal depiction of adolescent athletes' readiness to RTS after ACL injury throughout recovery. Both male and female athletes demonstrated diminished ACL-RSI scores before undergoing surgery, with increasing scores at both postoperative time points for both sexes. Overall, female athletes reported lower readiness to RTS at all 3 time points compared with male athletes.

Predicting ACL Reinjury from Return to Activity Assessments at 6-months Post-Surgery: A Prospective Cohort Study

CONTEXT

Return to activity(RTA) assessments are commonly administered following ACL-Reconstruction(ACLR) to manage post-operative progressions back to activity. To date, there is little knowledge on the clinical utility of these assessments to predict patient outcomes such as secondary ACL injury once returned to activity.

OBJECTIVE

To identify what measures of patient function at 6-months post-ACLR best predict return to activity and second ACL injury at a minimum of 2-years following ACLR.

DESIGN

Prospective-cohort Setting: Laboratory Patients: A total of 234 patients with primary, unilateral ACLR completed functional assessments at approximately 6-months post-ACLR. A total of 192(82%) completed follow-up ≥ 2-years post ACLR.

MAIN OUTCOME MEASURES

Six-month functional assessments consisted of patient reported outcomes, isokinetic knee flexor and extensor strength, and single-leg hopping. The ability to return to activity and secondary ACL injury were collected at a minimum of two-years following ACLR.

RESULTS

In patients who did RTA(n=155), a total of 44(28%) individuals had a subsequent ACL injury; graft n=24(15.5%), contralateral ACL n=20(13%). A greater proportion of females had a secondary injury to the contralateral ACL(15/24, 63%) whereas a greater proportion of males reinjured the ipsilateral ACL graft(15/20, 75%, P=.017) Greater knee extension symmetry at 6-months increased the probability of reinjury(B=.016, P=.048). In patients who RTA before 8-months, every 1% increase in quadriceps strength symmetry at 6-months increased the risk of reinjury by 2.1%(B=.021, P=.05). In patients who RTA after 8-months, every month that RTA was delayed reduced the risk of reinjury by 28.4%(B=-284, P=.042).

CONCLUSIONS

Patients with more symmetric quadriceps strength at 6-months post ACLR were more likely to experience another ACL rupture, especially in those who returned to sport earlier than 8-months after the index surgery. Clinicians should be cognizant that returning high functioning patients to activity earlier than 8-months post-ACLR may place them at an increased risk for reinjury.

Test Batteries After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

CONTEXT

There is a lack of consensus regarding test batteries for return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR).

OBJECTIVE

To report the RTS test batteries for individuals after ACLR and to examine alignment with the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC). Finally, to examine how published RTS batteries prior to the AAOS AUC (2010-2015) compared with those after publication of the AUC (2016-2020).

DATA SOURCE

A systematic search of PubMed (2010-2020).

STUDY SELECTION

Studies were included if they were published from 2010 to 2020, patients underwent primary ACLR and were tested between 6 months and 2 years postoperatively and included a minimum of 2 assessments. Studies were excluded if patients were tested outside the designated time; had undergone a revision, contralateral, or multiligament injury; included healthy participants; were level 5 evidence or the study was a systematic review. A total of 1012 articles were reviewed and 63 met the criteria.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Information regarding the RTS batteries and patient demographics were extracted from the included articles.

RESULTS

A total of 63 studies met the inclusion and exclusion criteria (22 from 2010-2015 and 41 from 2016-2020). The most common RTS batteries included the hop test, quadriceps strength test, and patient-reported outcome measures. No study met all 7 AUC; the most common criteria met were functional skills (98.4%), followed by confidence (22.2%), then range of motion and knee stability (20.6%).

CONCLUSION

The test batteries in the current literature show high variability and a lack of essential components necessary for RTS. No study met the AUC guidelines, suggesting a disconnect between recommended guidelines and clinical practice. Test battery research has expanded over the past decade; however, standardized, clinically applicable batteries that encompass all criteria are needed.

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

Background

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

Method

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

Results

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

Conclusion

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

Trial registration

 This trial was not registered.

Patient-Reported Outcomes, Return-to-Sport Status, and Reinjury Rates After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes: Minimum 2-Year Follow-up

Background

Significant variation exists in the published rates of return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR). Functional outcomes and psychological response to injury have been implicated as factors that influence return to sport. Most studies focus on patients aged in the mid-20s, and less is known about this topic in adolescents.

Purpose

To report midterm ACLR results for adolescent patients with regard to return to primary sport, patient-reported outcomes, and reinjury rate.

Study Design

Case-control study; Level of evidence, 3.

Methods

Adolescent athletes were contacted at a minimum of 2 years after ACLR. Patients completed 2 patient-reported outcome measures, the ACL--Return to Sport After Injury (ACL-RSI) and the International Knee Documentation Committee (IKDC) subjective form, and responded to questions regarding preinjury primary sport and level of competition, post-ACLR return to primary sport status, and reinjury.

Results

A total of 74 patients (mean ± SD surgical age, 15.9 ± 1.5 years; follow-up age, 19.9 ± 2.0 years; response rate, 24.5%) completed the surveys at a mean of 4.0 ± 2.0 years after primary ACLR. Outcome scores averaged 90.3 ± 12.3 for IKDC and 81.6 ± 20.4 for ACL-RSI. Questionnaire responses indicated that 27.0% of patients did not return to or sustain primary sport participation after ACLR; the principal reasons were poor knee function, team/training change, and fear of another injury. Both IKDC and ACL-RSI scores were statistically lower in patients who did not successfully return to their primary sport in contrast to patients who successfully resumed their primary sport (IKDC, P = .026; ACL-RSI, P < .001). IKDC and ACL-RSI scores were moderately positively correlated with one another (r _Spearman = 0.60). There were 18 patients (reinjury rate, 24.3%) who suffered another ACL injury; 8 of these injuries included ipsilateral ACL graft tear (retear rate, 10.8%).

Conclusion

In our cohort, 73% of adolescent patients successfully returned to their primary preinjury sport at a minimum of 2 years after ACLR. Both knee function and psychological responses to injury were important in determining an adolescent athlete's return to sport. The findings support the use of the IKDC and ACL-RSI at midterm follow-up, with higher scores associated with a greater likelihood of adolescent patients returning to sport after ACLR.

DETERMINANTS OF RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Objective:

To systematically review and meta-analyze the performance of return to play (RTP) and non-RTP patients in different assessment tools after anterior cruciate ligament reconstructions (ACLR).

Methods:

Out of 182 studies searched on PubMed, 11 presented RTP and non-RTP groups assessing the performance of young individuals, practitioners of different sports, with different tools.

Results:

There was higher limb symmetry (7.13% [95%CI 4.55; 9.70], p < 0.001), Tegner activity scale (2.41 [95%CI 0.18; 4.64], p = 0.03), functional scores such as International Knee Documentation Committee (x7.44 [95%CI 4.69; 10.19], p < 0.001), Knee Osteoarthritis Outcome score for quality of life (14.75 [95%CI 10.96; 18.54], p < 0.001) and for sports/recreation (11.86 [95%CI 8.87; 14.86], p < 0.001); and lower knee laxity (-0.25 mm [95%CI -0.36; -0.14], p < 0.001) in RTP compared to non-RTP patients following ACLR.

Conclusion:

We confirmed that these different tools can differentiate RTP for non-RTP patients, which may contribute to the physician’s decision about the ideal time for RTP. Level of Evidence III, Systematic review of Level III studies.

Limited evidence for return to sport testing after ACL reconstruction in children and adolescents under 16 years: a scoping review

Specific return to sport criteria for children and adolescents after anterior cruciate ligament injury and reconstruction are unknown. The aim of this scoping review is to provide an overview of current tests regarding return to sport for children and adolescents. This scoping review was performed according to the PRISMA statement. A systematic search was performed on PubMed and EMBASE. The inclusion criteria were diagnostic and prognostic studies evaluating tests regarding return to sport after ACL injury and reconstruction in children/adolescents (age < 18 years). Twenty-six studies were included, of which 22 studies evaluated tests in the age category of 16 to 18 years. All studies evaluated tests after ACL reconstruction, no studies have been conducted in non-operative patients. Strength tests, movement quality and patient reported outcomes measures (PROMs) are investigated most frequently. Clearance for return to sport should be based on a test battery including strength tests, movement quality during sport-specific tasks and (paediatric) patient reported outcome measures. There are no recommendations on which specific tests regarding quantity and quality of movement should be used. Future research should aim at at developing and validating a test battery including movement quality and neuromotor control in a sport-specific context for both younger children and adolescents after both operative and non-operative treatment.

The Use of Psychological Patient Reported Outcome Measures to Identify Adolescent Athletes at Risk for Prolonged Recovery Following an ACL Reconstruction

BACKGROUND

Psychological response to injury and the recovery process impact return to play and can put an athlete at risk for prolonged recovery. The purpose of this study was to investigate the psychological changes that occur surrounding an anterior cruciate ligament (ACL) reconstruction utilizing a set of patient reported outcomes measures (PROMs) that focus on psychological factors.

METHODS

Consecutive patients undergoing a primary ACL reconstruction, ages 12 to 18, were recruited. Patients were included if they verbalized a desire to return to the same sport and a baseline Tegner of >6. Functional and psychological PROMs were administered preoperatively, 6 months, and 1 year postoperatively. A Y-Balance Test was utilized to assess for clearance.

RESULTS

Of the 68 participants, 36 were female (52.9%) and 32 male, with a mean age of 14.5 years. On average, participants were cleared to return to sport 259.1 days postoperatively. Of the measures given preoperatively, only the Athletic Coping Skills Inventory-28 (ACSI)-28 correlated with delayed recovery time (rs=-0.291, P=0.04). Lower baseline ACSI-28 subscale scores in coachability (rs=-0.298, P=0.03) and Coping with Adversity (rs=-0.341, P=0.01) were correlated with delayed recovery. Participants that took longer than average to recover scored significantly lower on the ACSI-28 preoperatively than those with a shorter recovery time (62.04 vs. 54.8, P<0.01). Participants that scored <58 on their preoperative ACSI-28 took 2 months longer to recover than participants who scored ≥58 (9.6 vs. 7.65 mo, P<0.01). At 6 months postoperatively, higher ACSI-28 subscale Concentration (rs=-0.357, P<0.01) and Peaking Under Pressure (rs=-0.274, P=0.04) scores correlated with shorter recovery time.

CONCLUSIONS

The ACSI-28 significantly correlated with recovery time following ACL reconstruction. A baseline score of 58 may be a valuable cutoff to identify youth athletes at risk for prolonged recovery.

LEVEL OF EVIDENCE

Level II-prospective study.

Single leg aerobic capacity and strength in individuals with surgically repaired anterior cruciate ligaments

OBJECTIVES

Compare single-leg aerobic capacity and strength differences between the surgically repaired ACL leg (injured) and the uninjured leg.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PARTICIPANTS

Eight participants (5 female, 3 male, age = 23 ± 3.5 y, mass = 72.3 ± 17.3 kg, height = 169.7 ± 9.4 cm) that returned to play from ACL surgery between six and 18 months.

MAIN OUTCOME MEASURES

Participants performed an aerobically-based, single-leg cycling protocol to determine maximum oxygen consumption, ventilatory threshold, heart rate, rating of perceived exertion, and maximal watts cycled. Participants also performed isokinetic knee flexion and extension on a dynamometer to assess peak torque, total work, work fatigue, and power.

RESULTS

There were no statistical differences in single-leg aerobic capacity or strength outcomes between the injured and uninjured legs.

CONCLUSIONS

Individuals who have had an ACL surgically repaired six to 18 months after return to play do not appear to have aerobic capacity or strength deficits between the injured leg and uninjured leg.

Association of Strength Following Achilles Tendon Repair With Return to Same Level of Play in High-Level Athletes

BACKGROUND

Rupture of the Achilles tendon is a common injury and the ability to return to the same level of sporting activity after treatment is an important outcome for patients. The objective of the current study was to examine the relationship between ankle strength and the ability to return to previous level of play following operative repair of an Achilles tendon rupture.

METHODS

Patients aged 18 to 50 years at a minimum 1 year postoperation from surgical repair of an Achilles tendon returned for a study visit. Patients reported both preinjury and current activity level using the 10-point Tegner Activity Level Scale. Isokinetic strength testing was performed and the Isokinetic Strength Score (ISS) was calculated. Logistic regression analysis was used to determine the relationship between ISS and return to play by Tegner level. A total of 36 patients (mean 35 years old, 72% male) completed the study protocol at a mean 1.8 years postoperatively.

RESULTS

Logistic regression revealed no association between ISS and return to play in the complete cohort. Subgroup analysis revealed that for 20 high-level athletes (preinjury Tegner ≥ 7), for every 16-point increase in ISS, the odds ratio (OR) for return to same level of play was 8.3 (P = .055) and the OR for return to within 1 Tegner level of play was 6.3 (P = .043). There was no association between ISS and return to previous activity in the 16 patients with lower preinjury levels of activity.

CONCLUSION

Improved ankle strength was associated with return to previous level of activity in patients participating in high-level athletic activity, suggesting that these patients were more dependent on recovery of ankle strength in the postoperative time period in order to return to their previous high level of play. In contrast, regaining strength may be less important for returning to normal activities for less active patients.

LEVEL OF EVIDENCE

Level III, comparative series.

Psychosocial Barriers After Anterior Cruciate Ligament Reconstruction: A Clinical Review of Factors Influencing Postoperative Success

CONTEXT

Psychosocial factors arising after anterior cruciate ligament (ACL) injury may have a direct influence on an individual's decision to return to sport after ACL reconstruction (ACLR). While there is ample evidence to suggest that deficits in quadriceps strength, neuromuscular control, and clinical functional tasks exist after ACLR, the root and contribution of psychological dysfunction to an individual's success or return to sport after ACLR is still largely uncertain and unexplored. Given the discrepancy between successful functional outcomes and the percentage of athletes who return to sport, it is important to thoroughly address underlying factors, aside from physical function, that may be contributing to these lower return rates.

EVIDENCE ACQUISITION

Articles that reported on return to sport, psychological factors, and psychosocial factors after ACLR were collected from peer-reviewed sources available on Medline (1998 through August 2018). Search terms included the following: anterior cruciate ligament OR ACL AND return-to-sport OR return-to-activity, anterior cruciate ligament OR ACL AND psychological OR psychosocial OR biopsychosocial OR fear OR kinesiophobia OR self-efficacy, return-to-activity AND psychological OR psychosocial.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 5.

RESULTS

Psychosocial factors relative to injury are important components of the rehabilitation process. To fully understand how psychosocial factors potentially influence return to sport, an athlete's emotions, experiences, and perceptions during the rehabilitation process must be acknowledged and taken into consideration.

CONCLUSION

Acknowledgment of these psychosocial factors allows clinicians to have a better understanding of readiness to return to sport from a psychological perspective. Merging of the current ACLR rehabilitation protocols with knowledge related to psychosocial factors creates a more dynamic, comprehensive approach in creating a positive and successful rehabilitation environment, which may help improve return-to-sport rates in individuals after ACLR.

Identifying Meaningful Patient Outcomes After Lower Extremity Injury, Part 1: Patient Experiences During Recovery

CONTEXT

Determining meaningful aspects of health is crucial for outcome assessment; however, limited literature exists on the aspects of health that are deemed meaningful by the athletic patient population.

OBJECTIVE

To identify experiences and meaningful outcomes after lower extremity (LE) musculoskeletal injury among collegiate athletes.

DESIGN

Qualitative study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

A purposive sample of 20 athletes (10 men, 10 women; age = 20.1 ± 1.83 years) from a National Collegiate Athletic Association Division I institution in the Midwest who had sustained an LE injury.

DATA COLLECTION AND ANALYSIS

Semistructured face-to-face interviews and inductive data analysis were conducted. Trustworthiness of the data was established using member checks and peer debriefing.

RESULTS

Four themes emerged from the data, revealing that physical changes, psychological changes, personal and lifestyle changes, and support were the most meaningful outcomes among athletes with an LE injury. The 4 themes were associated with 21 subthemes, indicating the complexity with which LE injury affects individuals.

CONCLUSIONS

Our findings demonstrate the importance of caring for the whole person. Athletic trainers must broaden their focus to provide the best patient care and consider the person's activities and life demands outside of athletic participation. The themes identified in this study provide a basis for selecting appropriate health markers and outcome measures.

Pain and outcome prediction in muscle strength rehabilitation after knee injury in recreational athletes

Effects of rehabilitation on knee function, activity and health-related quality of life after soft-tissue knee injury have been widely studied in clinical trials, but there is still a lack of data on the relation between knee muscle strength and athlete's perceived performance to identify sports-risk modifiers. We performed a prospective observational clinical study of knee muscle strength and self-reported health during rehabilitation after unilateral knee soft-tissue injury in recreational sports. Forty-three patients performed isokinetic dynamometry and filled in the Short form Health Survey (SF-36) and the Oxford Knee Score questionnaires before and after 4 months of instructed home strengthening program. We observed significant improvement in peak torque deficit between two limbs during concentric extension (PTDE) and flexion, dynamic control ratio of the involved knee, most of the SF-36 subscales and the Oxford Knee Score values (P ≤ 0.001). Dynamic control ratio of the uninvolved knee values remained below referential values and unchanged. Improvement of PTDE correlated positively with improvement of the bodily pain subscale of SF-36 score (r = 0.51, P < 0.001). Receiver operating characteristic analysis indicated that reduction of pain by at least nine points predicts at least 10% reduction in PTDE, whereby the bodily pain change achieved poor (56%) sensitivity and good (86%) specificity as a rehabilitation success measure for recreational athletes after knee injury. Primary inferior eccentric strength of noninjured knee hamstrings might indicate increased risk of knee injury. Diminished perceived pain predicts strength improvement of the injured knee extensors with poor sensitivity and good specificity.