Return to play after anterior cruciate ligament reconstruction

Recent advances following anterior cruciate ligament reconstruction: rehabilitation perspectives : Critical reviews in rehabilitation medicine

Injuries to the anterior cruciate ligament are common. Surgical reconstruction is more prevalent than ever. This review article discusses treatment of the patient following surgical reconstruction of the anterior cruciate ligament. Various phases of rehabilitation are discussed with emphasis on early return of passive motion, early weight bearing, bracing, kinetic chain exercises, neuromuscular electrical stimulation and accelerated rehabilitation. Although evidence exists for the treatment of the surgically reconstructed cruciate ligament, more is needed to better define specific timeframes for advancement. Evidence exists that many of these young individuals are not fully returning to unlimited high level activities. This review article presents some of the latest evidence regarding anterior cruciate ligament rehabilitation in an attempt to help the busy clinician understand and relate basic and clinical research to rehabilitation of a patient following reconstruction.

No association of time from surgery with functional deficits in athletes after anterior cruciate ligament reconstruction: evidence for objective return-to-sport criteria

BACKGROUND

Release for full activity and return to sport after anterior cruciate ligament reconstruction (ACLR) is often dictated by time from surgery and subjective opinion by the medical team. Temporal guidelines for return to sport may not accurately identify impaired strength and neuromuscular control, which are associated with increased risk for second injury (contralateral and/or ipsilateral limb) after ACLR in athletes.

HYPOTHESES

Athletes undergoing ACLR and returning to sport would demonstrate functional deficits that would not be associated with time from surgery.

STUDY DESIGN

Controlled laboratory study.

METHODS

Thirty-three male (n = 10) and female (n = 23) athletes with unilateral ACLR, who were cleared by a physician to return to their sport after surgery and rehabilitation, performed the single-legged vertical hop test for 10 seconds on a portable force plate. Matched teammates of each patient were recruited to serve as sex-, sport-, and age-matched controls (CTRL; n = 67). Maximum vertical ground-reaction force (VGRF) was measured during each single-limb landing. Single-limb symmetry index (LSI) was calculated as the ratio of the involved divided by uninvolved limb, expressed as a percentage.

RESULTS

The single-limb vertical jump height LSI was reduced in the ACLR group, 89% (95% confidence interval [CI], 83%-95%), compared with the matched CTRL group, 101% (95% CI, 96%-105%; P < .01). The LSI for VGRF normalized to potential energy achieved during flight of the hop was increased in ACLR at 112% (95% CI, 106%-117%) relative to the CTRL group at 102% (95% CI, 98%-106%; P < .01). Linear regression analysis indicated that time from surgery was not associated with limb symmetry deficits in the ACLR group (P > .05; R (2) = .002-.01).

CONCLUSION

Deficits in unilateral force development (vertical jump height) and absorption (normalized VGRF) persist in an athlete's single-limb performance after ACLR and full return to sports. These symmetry deficits appear to be independent of time after reconstruction.

CLINICAL RELEVANCE

On the basis of these results, clinicians should consider assessment of single-limb power performance in the decision-making process for return-to-sport release. Persistent side-to-side asymmetries may increase the risk of contralateral and/or ipsilateral injury.

Clinical Outcomes and Return-to-Sports Participation of 50 Soccer Players After Anterior Cruciate Ligament Reconstruction Through a Sport-Specific Rehabilitation Protocol

Background:

Rehabilitation of soccer players after anterior cruciate ligament reconstruction is usually performed without sport-specific guidelines, and the final phases are often left to the team coaches. The possibility of changing this approach has not yet been investigated.

Study Design:

Case series.

Hypothesis:

A specific rehabilitation protocol for soccer players, with direct control of the last on-field rehabilitation phases, may lead to complete functional recovery.

Methods:

Fifty competitive soccer players who followed a sport-specific rehabilitation protocol for soccer were evaluated during the recovery period until their return to competition. The assessment of the functional outcomes was performed using the Knee Outcome Survey–Sports Activity Scale and isokinetic and aerobic fitness tests.

Results:

The average start of on-field rehabilitation was 90 ± 26 days after surgery; the average time to return to the competitions was 185 ± 52 days. The improvement in the Knee Outcome Survey–Sports Activity Scale during on-field rehabilitation was significant (P < 0.01; from 79 ± 15% to 96 ± 7%). The isokinetic and aerobic fitness tests showed a significant improvement of muscle strength (knee extensors, +55%, P < 0.01; knee flexors, +86%, P < 0.01) and aerobic threshold (+23%, P < 0.01) from the beginning to the end of on-field rehabilitation.

Conclusions:

Adding on-field rehabilitation to the traditional protocols after anterior cruciate ligament reconstruction may safely lead to complete functional recovery in soccer players.

Suggestions from the field for return to sports participation following anterior cruciate ligament reconstruction: soccer

Successful return to play remains a challenge for a soccer player after anterior cruciate ligament reconstruction. In addition to a successful surgical intervention, a soccer-specific functional rehabilitation program is essential to achieve this goal. Soccer-like elements should be incorporated in the early stages of rehabilitation to provide neuromuscular training specific to the needs of the player. Gym-based and, later, field-based drills are gradually intensified and progressed until the player demonstrates the ability to return to team practice. In addition to the recovery of basic attributes such as mobility, flexibility, strength, and agility, the surgically repaired knee must also regain soccer-specific neuromuscular control and conditioning for an effective return to sports. The individual coaching of the player by the sports physiotherapist and compliance with the training program by the player are key factors in the rehabilitation process. To minimize reinjury risk and to maximize the player's career, concepts of soccer-specific injury prevention programs should be incorporated into the training routine during and after the rehabilitation of players post-ACL reconstruction.

Return to Sports after Articular Cartilage Repair in the Football (Soccer) Player

BACKGROUND

The ability to return to football (soccer) presents a critical aspect for successful treatment of articular cartilage injury in the football (soccer) player.

METHODS

Information about sports participation after articular cartilage repair was collected from the literature. Special focus was placed on data in football athletes with information on return rate, timing of return, level of postoperative competition, and the ability to compete in the sport over time.

RESULTS

Twenty studies describing 1,469 athletes including football players with articular cartilage injury were reviewed. Average return to sport was 79% without a significant difference in return rate or postoperative level of play between cartilage repair techniques. Time to return varied between 7 to 17 months, with the longest time for autologous chondrocyte transplantation (ACI). Advanced sport-specific rehabilitation was able to reduce recovery time. Durability of results was best after ACI, with up to 96% continued sport participation after more than 3 years. Player age, time between injury and treatment, competitive level, defect size, and repair tissue morphology affected the ability to return to play. Sports participation after cartilage repair generally promoted joint restoration and functional recovery.

CONCLUSIONS

Articular cartilage repair allows for a high rate of return to high-impact sports including football, often at the preinjury competitive level. The time of return and durability can be variable and depend on repair technique and athlete-specific factors. Advanced, sport-specific rehabilitation can facilitate return to football.

Microfracture in Football (Soccer) Players: A Case Series of Professional Athletes and Systematic Review

BACKGROUND

Little information is available on the results of microfracture in competitive football (soccer) players. We aimed to evaluate the efficacy of this technique to restore joint function to a level that allows return to this popular high-impact sport.

METHODS

This article provides an overview of the basic science and the current published scientific evidence for articular cartilage repair using the microfracture technique in elite football (soccer) athletes. In addition, the senior author documents his results in a case series of professional football (soccer) players treated with microfracture.

RESULTS

Twenty-one professional male soccer players underwent microfracture for knee articular cartilage defects. Nineteen players had isolated cartilage injuries, and 2 players had simultaneous anterior cruciate ligament injuries. Average age of the player was 27 years (range, 18-32 years). Twelve players (57%) had single defects, and 9 (43%) had multiple defects. All players complied with the postoperative rehabilitation program. Twenty players (95%) returned to professional soccer the season following microfracture surgery and continued to play for an average of 5 years (range, 1-13 years). Years of continued play inversely correlated with player age at the time of microfracture (r = -0.41).

CONCLUSION

Articular cartilage repair with the microfracture technique followed by appropriate rehabilitation provides restoration of knee joint function in professional football (soccer) players with a high rate of return to football (soccer) and continued participation under the significant demands of professional football (soccer). Thorough understanding of the technical aspects, rehabilitation, and literature can help to optimize the results of microfracture in the athletic population.

Effectiveness of cryotherapy after anterior cruciate ligament reconstruction

OBJECTIVE

The purpose of this study was to evaluate cryotherapy effectiveness in the immediate postoperative period of ACL reconstruction to improve pain and range of motion (ROM) of the knee.

METHODS

This is a pilot study of a prospective and randomized clinical trial. Patients (n=25) were divided into two groups: Intervention (A) group (n=10): patients were submitted to an inpatient physical therapy protocol and received ice compress for 20 minutes, twice a day; Control (B) group (n=9): patients had the same protocol, twice a day. The pain intensity was evaluated with the visual analogic scale (VAS) and range of motion was measured with a goniometer.

RESULTS

The Intervention (A) group had important absolute and percentual improvement when compared with the Control (B) group regarding measures of pain and knee flexion/extension ROM.

CONCLUSION

Cryotherapy in the immediate postoperative period of ACL reconstruction was effective to improve pain and range of motion of the knee. Level of Evidence I, Randomized Clinical Trial .

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

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

Anterior cruciate ligament reconstruction: a multicenter prospective cohort study evaluating 3 different grafts using same bone drilling method

OBJECTIVE

To compare the clinical outcomes after anterior cruciate ligament (ACL) reconstruction with bone-patellar tendon-bone autograft (BPTBAu), BPTB allograft (BPTBAll), or hamstring (semitendinosus-gracilis) tendon autograft (HTAu), performing bone drilling with same methods in terms of transtibial drilling, orientation, positioning, and width of femoral and tibial tunnels.

DESIGN

Multicenter prospective cohort study (level of evidence II).

SETTING

Departments of Orthopedic Surgery of Centro Médico Teknon (Barcelona, Spain) Clínica Universitaria de Navarra (Navarra, Spain), and Clínica FREMAP (Gijón, Spain).

PATIENTS

All patients with ACL tears attending 3 different institutions between January 2004 and June 2006 were approached for eligibility and those meeting inclusion criteria finally participated in this study.

INTERVENTION

Each institution was assigned to perform a specific surgical technique. Patients were prospectively followed after undergoing ACL reconstruction with BPTBAu, BPTBAll, or HTAu, with a minimum follow-up of 24 months.

MAIN OUTCOME MEASURES

Included knee laxity and International Knee Documentation Committee (IKDC) score. Knee laxity was assessed with the KT-1000 arthrometer (evaluated with neutral and external rotation positions) and both Lachman and pivot shift tests. Additional outcomes included main symptoms (anterior knee pain, swelling, crepitation, and instability), disturbance in knee sensation, visual analogue scale (VAS) for satisfaction with surgery, range of motion (ROM), and isokinetic knee strength.

RESULTS

There were no significant differences among the 3 groups for any of the clinical outcomes, except for a slightly greater KT-1000-measured knee laxity in external rotation in the BPTBAu compared with the other groups. All patients demonstrated grade A or B of the IKDC. The mean VAS for satisfaction with surgery in all patients was 8.5.

CONCLUSIONS

The selection of the surgical technique for ACL reconstruction may be based on the surgeon's preferences.

Return to the preinjury level of competitive sport after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned by 12 months after surgery

BACKGROUND

An athlete's desire to return to sport after anterior cruciate ligament (ACL) injury is a major indication for ACL reconstruction surgery. Typical clearance to return is 6 to 12 months postoperatively.

PURPOSE

To investigate the return-to-sport rate and participation level of a large cohort at 12 months after ACL reconstruction surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were analyzed for 503 patients who participated in competitive-level Australian football, basketball, netball, or soccer after ACL reconstruction surgery using a quadruple-strand hamstring autograft. Inclusion criteria included participation in competitive sport before the ACL injury and clearance from the orthopaedic surgeon to return to sport postoperatively. Patients completed a self-report questionnaire regarding preoperative and postoperative sports participation and the Cincinnati Sports Activity Scale. The International Knee Documentation Committee (IKDC) knee evaluation form and hop tests were used to evaluate knee function.

RESULTS

Sixty-seven percent of patients attempted some form of sports activity by 12 months postoperatively; 33% attempted competitive sport. Of those who did not attempt any sports activity by 12 months, 47% indicated that they were planning to return. Men were significantly more likely than women to return. Patients who played sports with a seasonal competition, versus a year-round competition, were significantly more likely to return by 12 months. Patients with normal postoperative knee function (IKDC category A), versus those with nearly normal function (IKDC category B), were no more likely to return, but patients with good hop test results (≥85% limb symmetry index) were more likely to return than patients with poor results (<85%).

CONCLUSION

People may require a longer postoperative rehabilitation period than that typically advocated to facilitate a successful return to competitive sport after ACL reconstruction surgery. The relationship between postoperative knee function and return-to-sport outcomes at 12 months after surgery was inconclusive.

The relationship between functional levels and fear-avoidance beliefs following anterior cruciate ligament reconstruction

Background

The purpose of this study is to assess the relationship between functional levels in activities of daily living and sports and fear-avoidance beliefs in patients with a history of anterior cruciate ligament reconstruction (ACLR), after controlling for injury-related variables and physical impairment measures.

Patients and methods

Forty-eight subjects (34 men, 14 women; age 20.6 ± 1.2 years), at a mean of 31.7 ± 16.2 months following ACLR, participated in this study. Functional levels in activities of daily living and sports were assessed with the Knee Outcome Survey (KOS) Activities of Daily Living Scale (ADLS) and Sports Activity Scale (SAS). Fear-avoidance beliefs were assessed with the physical activity subscale of the fear-avoidance beliefs questionnaire (FABQ), which was adapted for use in patients with knee pathology. Injury-related variables included whether or not additional knee surgery was performed after the initial ACLR and the number of months from the most recent ACLR to participation in this study. Physical impairment measures included single-leg hop capabilities, quadriceps strength, and anterior knee joint laxity.

Results

Hierarchical linear regression analysis revealed that scores on the physical activity subscale of the FABQ contributed significantly to KOS ADLS and SAS scores after accounting for injury-related variables and physical impairment measures. The final regression model accounted for 61% of the variance in KOS ADLS and SAS scores (P < 0.001).

Conclusion

These results suggest that fear-avoidance beliefs following ACLR can potentially adversely influence functional levels in activities of daily living and sports.

Current concepts in ACL Injuries

Anterior cruciate ligament (ACL) injuries are common in athletic and physically active populations, and can result in significant functional disability. Female athletes in particular have been found to be at a relatively high risk for noncontact ACL injuries. Many risk factors, both intrinsic and extrinsic, have been identified. Although some individuals may be treated nonoperatively with an aggressive rehabilitation program, athletes desiring to return to physical activities that require use of the ACL need surgical reconstruction. Surgical techniques remain controversial in regard to tunnel placement and optimal graft choices. Recent literature advocates a more oblique ACL reconstruction to more closely recreate normal knee kinematics and eliminate pathologic rotational laxity. A supervised and intensive rehabilitation program is necessary to achieve desired results. Anatomic and neuromuscular risk factors, often gender related, are the focus of most ACL injury prevention programs.

Evidence-based rehabilitation following anterior cruciate ligament reconstruction

Following a bone-patellar tendon-bone autograft (BPTB) or four-stranded semitendinosus/gracilis tendons autograft (ST/G) anterior cruciate ligament (ACL) reconstruction, the speed and safety with which an athlete returns to sports (or regains the pre-injury level of function) depends on the rehabilitation protocol. Considering the large differences in clinical and outpatient protocols, there is no consensus regarding the content of such a rehabilitation program. Therefore, we conducted a systematic review to develop an optimal evidence-based rehabilitation protocol to enable unambiguous, practical and useful treatment after ACL reconstruction. The systematic literature search identified 1,096 citations published between January 1995 and December 2006. Thirty-two soundly based rehabilitation programs, randomized clinical trials (RCT's) and reviews were included in which common physical therapy modalities (instruction, bracing, cryotherapy, joint mobility training, muscle-strength training, gait re-education, training of neuromuscular function/balance and proprioception) or rehabilitation programs were evaluated following ACL reconstruction with a BPTB or ST/G graft. Two reviews were excluded because of poor quality. Finally, the extracted data were combined with information from background literature to develop an optimal evidence-based rehabilitation protocol. The results clearly indicated that an accelerated protocol without postoperative bracing, in which reduction of pain, swelling and inflammation, regaining range of motion, strength and neuromuscular control are the most important aims, has important advantages and does not lead to stability problems. Preclinical sessions, clear starting times and control of the rehabilitation aims with objective and subjective tests facilitate an uncomplicated rehabilitation course. Consensus about this evidence-based accelerated protocol will not only enhance the speed and safety with which an athlete returns to sports, but a standardized method of outcome measurement and reporting will also increase the evidential value of future articles.

Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up

Drilling of the femoral tunnel with the transtibial (TT) technique is widely used in bone-patellar tendon-bone (BPTB) anterior cruciate ligament (ACL) reconstruction. Recent studies suggest higher knee stability with the use of the anteromedial portal (AMP). The purpose of this study was to compare functional and clinical outcomes of BPTB ACL reconstruction using the TT or the AMP technique for drilling the femoral tunnel. All ACL reconstructions between January 2003 and April 2006 were approached for eligibility. Forty-seven patients met inclusion criteria (21 TT group and 26 AMP group). Blinded assessments of IKDC score, knee stability and range of motion, one-leg hop test, mid-quadriceps circumference, VAS for satisfaction with surgery, Lysholm and Tegner scores, and SF-12 questionnaire were obtained for both groups. Data on preoperative and postoperative surgical timing were retrospectively reviewed through the charts. The AMP group demonstrated a significantly lower recovery time from surgery to walking without crutches (p < 0.01), to return to normal life (p < 0.03), to return jogging (p < 0.03), to return training (p < 0.03), and to return to play (p < 0.03). Knee stability values measured with KT-1000, Lachman test, pivot-shift sign, and objective IKDC score assessments were significantly better for the AMP compared to TT group (p < 0.002, p < 0.03, p < 0.02, p < 0.015, respectively). No differences were found for VAS for satisfaction with surgery, Lysholm, Tegner, and SF-12 between both groups. The use of the AMP technique significantly improved the anterior-posterior and rotational knee stability, IKDC scores, and recovery time from surgery compared to the TT technique.

Clinical Outcome and Return to Competition after Microfracture in the Athlete's Knee: An Evidence-Based Systematic Review

Microfracture is frequently used for articular cartilage repair in athletes. This study aimed to define the strength and weaknesses of this minimally invasive cartilage repair technique in the athletic population in an effort to optimize indications, functional outcome, and athletic participation after microfracture in the athlete's knee. A systematic analysis of original studies using microfracture in athletes was performed. Functional outcome was assessed by activity outcome scores, ability to return to sports participation, timing of the return to sport, level of postoperative sports activity, and continuation of athletic competition over time. Thirteen studies describing 821 athletes were included in the analysis with an average follow-up of 42 months. Good or excellent results were reported in 67% of athletes with normal International Knee Documentation Committee (IKDC) scores in 80% and significant increase of Lysholm scores, Tegner activity scores, and Knee injury and Osteoarthritis Outcome Score (KOOS) sports subscales. Return to sports was achieved in 66% at an average of 8 months after surgery, with return to competition at the preinjury level in 67%. Forty-nine percent of athletes continued to compete without change in level of play, while decreasing function was observed in 42% after 2 to 5 years. Athlete's age, preoperative duration of symptoms, level of play, lesion size, and repair tissue morphology affected sports activity after microfracture. Microfracture improves knee function and frequently allows for return to sports at the preinjury level, but deterioration of athletic function occurs in some patients. Several independent factors were identified that can help to optimize the return to athletic competition after microfracture in the athlete's knee.

Knee stability and movement coordination impairments: knee ligament sprain

The Orthopaedic Section of the American Physical Therapy Association presents this fourth set of clinical practice guidelines on knee ligament sprain, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

J Orthop Sports Phys Ther 2010;40(4):A1–A37. doi:10.2519/jospt.2010.0303

Methodological report: dynamic field tests used in an NFL combine setting to identify lower-extremity functional asymmetries

Side-to-side differences in lower-extremity biomechanics may be predictive of increased risk of lower-extremity injuries in athletes. The purpose of this report is to provide field testing methodology for tests designed to isolate lower-extremity asymmetry and to demonstrate the potential for these tests to provide reliable measures. Six athletes (3 females, 3 males) were tested on 2 consecutive days for activities incorporated into a replicated National Football League (NFL) combine setting. Vertical hop power (VHP) and jump height were measured on a portable force platform as athletes performed maximum effort hops for 10 seconds. The modified agility T-test (MAT) incorporates two 90-degree single-leg cuts during the trial and was measured as total time for completion. Intraclass correlations (within ICC [3,k], between ICC [3,1]) were calculated. The VHP test had good to excellent within-session reliability for peak power of both the right (ICC = 0.942) and left (ICC = 0.895) sides. Jump height showed excellent within-session reliability for both the right (ICC = 0.963) and left (ICC = 0.940) sides. The between-session reliability for peak power between jumps was good for the right (ICC = 0.748) and left (ICC = 0.834) sides. Jump height showed good to excellent between-session reliability on the right (ICC = 0.794) and left (ICC = 0.909) sides. The MAT also showed good reliability between days (ICC = 0.825).The results indicate that the VHP test provides reliable assessment of both within- and between-session jump height and power production. The MAT also provides good reliability between testing days. Both the VHP and the MAT may be useful for clinicians to identify the presence of lower-limb asymmetry and potential injury risk factors in athletic populations.

Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction

STUDY DESIGN

Randomized clinical trial.

OBJECTIVES

Determine effective interventions for improving readiness to return to sports postoperatively in patients with complete, unilateral, anterior cruciate ligament (ACL) rupture who do not compensate well after the injury (noncopers). Specifically, we compared the effects of 2 preoperative interventions on quadriceps strength and functional outcomes.

BACKGROUND

The percentage of athletes who return to sports after ACL reconstruction varies considerably, possibly due to differential responses after acute ACL rupture and different management. Prognostic data for noncopers following ACL reconstruction is absent in the literature.

METHODS

Forty noncopers were randomly assigned to receive either progressive quadriceps strength-training exercises (STR group) or perturbation training in conjunction with strength-training exercises (PERT group) for 10 preoperative rehabilitation sessions. Postoperative rehabilitation was similar between groups. Data on quadriceps strength indices [(involved limb/uninvolved limb force) x 100], 4 hop score indices, and 2 self-report questionnaires were collected preoperatively and 3, 6, and 12 months postoperatively. Mann-Whitney U tests were used to compare functional differences between the groups. Chi-square tests were used to compare frequencies of passing functional criteria and reasons for differences in performance between groups postoperatively.

RESULTS

Functional outcomes were not different between groups, except a greater number of patients in the PERT group achieved global rating scores (current knee function expressed as a percentage of overall knee function prior to injury) necessary to pass return-to-sports criteria 6 and 12 months after surgery. Mean scores for each functional outcome met return-to-sports criteria 6 and 12 months postoperatively. Frequency counts of individual data, however, indicated that 5% of noncopers passed RTS criteria at 3, 48% at 6, and 78% at 12 months after surgery.

CONCLUSION

Functional outcomes suggest that a subgroup of noncopers require additional supervised rehabilitation to pass stringent criteria to return to sports.

LEVEL OF EVIDENCE

Therapy, level 2b.Note: If watching the first video, we recommend downloading and referring to the accompanying PowerPoint slides for any text that is not readable.

Current controversies in rehabilitation after anterior cruciate ligament reconstruction

Rehabilitation concepts after anterior cruciate ligament (ACL) reconstruction continue to advance rapidly. A review of the recent literature reveals numerous aspects of the rehabilitation program, the subject of investigation, and validation. Areas discussed in this article include the efficacy of functional bracing after ACL reconstruction and perturbation training programs in nonoperative, preoperative and postoperative rehabilitation programs. Also discussed is the need for criteria-based progression through the late stages (return to sports) of the ACL reconstruction rehabilitation.

Return to sports participation after articular cartilage repair in the knee: scientific evidence

BACKGROUND

Articular cartilage injury in the athlete's knee presents a difficult clinical challenge. Despite the importance of returning injured athletes to sports, information is limited on whether full sports participation can be successfully achieved after articular cartilage repair in the knee.

HYPOTHESIS

Systematic analysis of athletic participation after articular cartilage repair will demonstrate the efficacy of joint surface restoration in high-demand patients and help to optimize outcomes in athletes with articular cartilage injury of the knee.

STUDY DESIGN

Systematic review.

METHODS

A comprehensive literature review of original studies was performed to provide information about athletic participation after articular cartilage repair. The athlete's ability to perform sports postoperatively was assessed by activity outcome scores, rate of return to sport, timing of the return, level of postoperative sports participation, and the continuation of athletic activity over time.

RESULTS

Twenty studies describing 1363 patients were included in the review, with an average follow-up of 42 months. Return to sports was possible in 73% overall, with highest return rates after osteochondral autograft transplantation. Time to return to sports varied between 7 and 18 months, depending on the cartilage repair technique. Initial return to sports at the preinjury level was possible in 68% and did not significantly vary between surgical techniques. Continued sports participation at the preinjury level was possible in 65%, with the best durability after autologous chondrocyte transplantation. Several factors affected the ability to return to sport: athlete's age, preoperative duration of symptoms, level of play, lesion size, and repair tissue morphology.

CONCLUSION

Articular cartilage repair in the athletic population allows for a high rate of return to sports, often at the preinjury level. Return to sports participation is influenced by several independent factors. The findings provide pertinent information that is helpful for the clinical decision-making process and for the management of the athlete's postoperative expectations.

Effect of anterior cruciate ligament injury and reconstruction on proprioceptive acuity of knee rotation in the transverse plane

BACKGROUND

Studies assessing proprioceptive acuity in anterior cruciate ligament (ACL)-deficient knees have only considered proprioception for knee movements in the sagittal plane rather than in the transverse plane (ie, rotation), despite the fact that the ACL plays a critical role in knee rotational stability and that the ACL is injured almost exclusively with a rotation mechanism. Therefore a test of proprioception is needed that involves movements similar to the mechanism of injury, in this case, rotation.

PURPOSE

To determine whether proprioceptive acuity in rotation changes after ACL injury and reconstruction, and to examine differences in proprioceptive acuity, range, laxity, and activity level among injured knees, contralateral knees, and healthy controls.

DESIGN

Cohort study; Level of evidence, 2.

METHODS

Proprioceptive acuity for active knee rotation movements, passive rotation range of motion, anterior knee laxity, and knee function were measured in 20 consecutive participants with unilateral ACL rupture and 20 matched controls. Reconstruction was performed using a single-incision technique with a 4-strand hamstring tendon autograft. Thirty participants (15 control and 15 ACL reconstructed) were retested at 3 months, and 14 with ACL reconstruction were tested at 6 months.

RESULTS

A deficit was found in preoperative knee rotation proprioception compared with healthy controls (P = .031). Three months after reconstruction, there was a significant improvement (P = .049) in proprioceptive acuity, single-plane anterior laxity (P = .01), and self-reported knee function (P = .001). At 3 months after reconstruction, proprioceptive acuity of the ACL-reconstructed knee was correlated with reported activity level (r = .63; P = .021).

CONCLUSION

Knee rotation proprioception is reduced in ACL-deficient participants compared with healthy controls. Three to 6 months after reconstruction, rotation proprioceptive acuity, laxity, and function were improved. While these findings are consistent with a return to previous activity level 6 months after reconstruction, the extent of graft maturation and restoration of kinematics should also inform the decision about return to sport.

Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction

Surgical intervention and early-phase rehabilitation after anterior cruciate ligament (ACL) reconstruction have undergone a relatively rapid and global evolution over the past 25 years. Despite the advances that have significantly improved outcomes, decreases in healthcare coverage (limited visits allowed for physical therapy) have increased the role of the strength and conditioning specialist in the rehabilitation of athletes returning to sport after ACL reconstruction. In addition, there is an absence of standardized, objective criteria to accurately assess an athlete's ability to progress through the end stages of rehabilitation and safely return to sport. The purpose of this Scientific Commentary is to present an example of a progressive, end-stage return to sport protocol that is targeted to measured deficits of neuromuscular control, strength, power, and functional symmetry that are rehabilitative landmarks after ACL reconstruction. The proposed return to sport training protocol incorporates quantitative measurement tools that will provide the athlete with objective feedback and targeted goal setting. Objective feedback and targeted goal setting may aid the strength and conditioning specialist with exercise selection and progression. In addition, a rationale for exercise selection is outlined to provide the strength and conditioning specialist with a flexible decision-making approach that will aid in the modification of return to sport training to meet the individual athlete's abilities and to target objectively measured deficits. This algorithmic approach may improve the potential for athletes to return to sport after ACL reconstruction at the optimal performance level and with minimized risk of reinjury.

Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase

Rehabilitation following anterior cruciate ligament (ACL) reconstruction has undergone a relatively rapid and global evolution over the past 25 years. However, there is an absence of standardized, objective criteria to accurately assess an athlete's ability to progress through the end stages of rehabilitation and safe return to sport. Return-to-sport rehabilitation, progressed by quantitatively measured functional goals, may improve the athlete's integration back into sport participation. The purpose of the following clinical commentary is to introduce an example of a criteria-driven algorithm for progression through return-to-sport rehabilitation following ACL reconstruction. Our criteria-based protocol incorporates a dynamic assessment of baseline limb strength, patient-reported outcomes, functional knee stability, bilateral limb symmetry with functional tasks, postural control, power, endurance, agility, and technique with sport-specific tasks. Although this algorithm has limitations, it serves as a foundation to expand future evidence-based evaluation and to foster critical investigation into the development of objective measures to accurately determine readiness to safely return to sport following injury.

Plyometric exercise in the rehabilitation of athletes: physiological responses and clinical application

Plyometric exercise was initially utilized to enhance sport performance and is more recently being used in the rehabilitation of injured athletes to help in the preparation for a return to sport participation. The identifying feature of plyometric exercise is a lengthening of the muscle-tendon unit followed directly by shortening (stretch-shortening cycle). Numerous plyometric exercises with varied difficulty and demand on the musculoskeletal system can be implemented in rehabilitation. Plyometric exercises are initiated at a lower intensity and progressed to more difficult, higher intensity levels. The progression to higher-intensity plyometric exercise is thought to resolve postinjury neuromuscular impairments and to prepare the musculoskeletal system for rapid movements and high forces that may be similar to the demands imposed during sport participation, thus assisting the athlete with a return to full function. While there is a large body of scientific literature that supports the use of plyometric exercise to enhance athletic performance, evidence is sparse regarding the effectiveness of plyometric exercise in promoting a quick and safe return to sport after injury. This review will describe the mechanisms involved in plyometric exercise, discuss the considerations for implementing plyometric exercise into rehabilitation protocols, examine the evidence supporting the use of plyometric exercises, and make recommendations for future research.