Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study

Precision Anterior Cruciate Ligament Reconstruction

Precision anterior cruciate ligament reconstruction (ACLR) refers to the individualized approach to prerehabilitation, surgery (including anatomy, bony morphology, and repair/reconstruction of concomitant injuries), postrehabilitation, and functional recovery. This individualized approach is poised to revolutionize orthopedic sports medicine, aiming to improve patient outcomes. The purpose of this article is to provide a summary of precision ACLR, from the time of diagnosis to the time of return to play, with additional insight into the future of ACLR.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Limited correlation between physical performance and patient-reported outcomes at 1-year follow-up after anterior cruciate ligament reconstruction

Purpose

The majority of anterior cruciate ligament reconstruction (ACLr) patients wish to return to sport. Clinical evaluations after ACLr often do not include physical testing, making it difficult to determine the patient's readiness to return to sport. Thus, it would be helpful to identify easily assessable factors associated with physical function in ACLr patients that could inform planning of patients' return to sport. This study sought to evaluate the associations between physical test performance in ACLr patients and known ACL injury risk factors, knee laxity and patient-reported outcomes at 1-year follow-up.

Methods

The cohort included isolated primary ACLr patients operated between 2009 and 2014. Patients were invited to a 1-year visit to clarify their readiness to return to sport. A test battery was performed, including clinical evaluation, patient-reported outcomes and three physical tests, from which the Leg Symmetry Index (LSI) was calculated. Multivariate regression analyses were performed for each of the physical tests, including known risk factors, clinical outcomes and patient-reported outcomes. Laxity <3 mm, pivot shift = 0, Knee Injury and Osteoarthritis Outcome Score (KOOS) sport >75, International Knee Documentation Committee (IKDC) >75.9, and Single Assessment Numeric Evaluation (SANE) >92.7 were applied as cut-off values for good versus poor status.

Results

A total of 480 ACLr patients were included in the study. Laxity <3 mm had a negative impact on the single-hop LSI, whereas a pivot shift = 0 or IKDC >75.9 had a positive impact on the single-hop LSI. Age <20, a pivot shift grade of 0 and KOOSsport >75 were positively associated with the triple-hop LSI. Finally, age <20 and IKDC >75.9 were positively associated with the leg extension strength LSI.

Conclusions

Age, sagittal laxity, pivot shift and patient-reported outcomes were associated with physical test performance 1 year after ACLr. However, the associations were not completely uniform and strong, so information on age, sagittal laxity, pivot shift and patient-reported outcomes cannot replace a return-to-sport functional test battery in determining when it is safe to return to sport after ACLr.

Level of Evidence

Level III.

Time to Reflect on Return to Sport Timing Following ACL Reconstruction

The time of return to sport following anterior cruciate ligament (ACL) reconstruction is a commonly discussed topic within clinical settings and the sports medicine literature. Emerging science has demonstrated protective effects of delaying the time of sport clearance on athlete reinjury. Though a single time cutoff is unlikely to be applicable for all athletes, large inconsistencies in the time of return to sport clearance are present in both the literature and within prescribed clinical protocols. A multitude of patient factors, such as perceived function, objective function, confidence, post-operative goals, among others, are vital for how athletes are progressed and released for sport participation. This Current Opinion article is constructed to discuss the time to return to sport after ACL reconstruction-factors that may influence timing decisions, how time is assessed within the scientific literature-and to promote discussion on this common topic within the sports medicine and athletic communities. The aim of the article is not to establish defined clinical time cutoffs for this population.

Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction

Rehabilitation after an anterior cruciate ligament (ACL) reconstruction requires patience, devotion, and discipline. Rehabilitation should be individualized to each patient's specific need and sport. Return to sport is a continuum throughout the rehabilitation, and patients should not return to performance before passing a battery of muscle function tests and patient-reported outcomes, as well as change of direction-specific tests. Return to full participation should be an agreement between the patient, physical therapist, surgeon, and coach. For minimal risk for second ACL injury, patients should continue with maintenance and prevention training even after returning to sport.

Relationship between hamstring strength and hop performance at 8 and 12 months after ACL reconstruction with hamstring tendon autografts

BACKGROUND

The relationship between hamstring strength and hop performance after anterior cruciate ligament (ACL) reconstruction with hamstring tendon (HT) autografts has not been well elucidated. The aim was to investigate the relationship between eccentric hamstring strength, assessed with the NordBord, and concentric hamstring strength, assessed with the Biodex, with hop performance at 8 and 12 months after ACL reconstruction.

METHODS

Registry study. Patients ≥ 16 years who had undergone primary ACL reconstruction with HT autograft, followed by muscle strength and hop tests at 8 and 12 months were included. Correlations of the relative hamstring strength (Nm/kg or N/kg) and limb symmetry index (LSI) with hop performance were analyzed. Pearson's correlation coefficient, and coefficient of determination (r2) were used for statistical analysis.

RESULTS

A total of 90 patients were included, of which 48 (53%) were women. The mean age at ACL reconstruction was 27.0 ± 8.0 years. Relative hamstring strength had significant positive correlations with hop performance, ranging from r = 0.25-0.66, whereas hamstring strength LSI had significant positive correlations which ranged from r = 0.22-0.37 at 8 and 12 months after ACL reconstruction. At 12 months, the relative hamstring strength in the Biodex explained 32.5-43.6% of the hop performance in vertical hop height, hop for distance relative to height, and the total number of side hops, whereas the relative hamstring strength in the NordBord explained 15.2-23.0% of the hop performance.

CONCLUSION

The relative hamstring strength in the Biodex test explained 32.5-43.6% of the hop performance, whereas the relative hamstring strength in the NordBord explained 15.2-23.0%. Thus, our findings suggest that relative hamstring strength, especially in the hip-flexed position may be a better indicator of hop performance at 8 and 12 months after ACL reconstruction in patients treated with HT autograft.

Athletes' perspectives on return to sport after anterior cruciate ligament reconstruction and their strategies to reduce reinjury risk: a qualitative interview study

BACKGROUND

Insights derived from athletes who have completed the final phase of rehabilitation and successfully returned to their respective sports after anterior cruciate ligament (ACL) reconstruction could potentially contribute to the enhancement of therapeutic strategies. Therefore, the aim of this study was to explore athletes' experiences, thoughts, and behaviours of final phase rehabilitation and return to sport after ACL reconstruction and to describe their thoughts about the risk of reinjury.

METHODS

This qualitative interview study included individual semi-structured interviews with 15 athletes after ACL reconstruction. All athletes were aged between 15 and 35 years (median, 23 years), had returned to their preinjury contact sport at elite or recreational competitive level, rehabilitated with different physioterapists (working in hospital, primary care or sport clinics), and had undergone primary ACL reconstruction between 14 and 59 months (median, 23 months) before the interviews. Data were analysed using qualitative content analysis.

RESULTS

Analysis of the data resulted in the following 4 main categories related to athletes' experiences of the return to sport process and their thoughts about the risk of reinjury: Athletes' strategies for safe return to sport; Support during rehabilitation and return to sport; The rehabilitation journey was worthwhile to be able to play again; and Reinjury is beyond one's control.

CONCLUSIONS

Athletes described strategies for a safe return to sport after ACL reconstruction, emphasizing continuous increased load, not forcing return to sport, injury prevention exercises, and seeking support from professionals and coaches. Despite loving their sport, the athletes had mixed feelings about undergoing additional rehabilitation if reinjured. The athletes recognized the high reinjury risk, attributing it to fate. These findings enhance understanding of athletes' return to sport experiences after ACL reconstruction, their strategies to minimize reinjury risk, which might help optimizing care for this patient group.

Reliability and Validity of Temporal Parameters during the Side Hop Test in Patients after Anterior Cruciate Ligament Reconstruction

Background: The side hop test (SHT) measures the number of jumps performed over 30 s. Although this measure has demonstrated its value in clinical practice, the temporal parameters of the SHT allow for a deeper analysis of the execution strategy. The aim of this study is to assess the reliability and construct validity of contact time parameters during the SHT recorded by a video analysis system in anterior cruciate ligament reconstructed (ACLR) patients. Methods: We investigated the reliability (intra-rater, standard error of measurement (SEM), and minimum detectable change (MDC)), discriminant validity (operated (OP) versus non-operated (NOP) side), and convergent validity (relationship with strength and psychological readiness) of SHT contact time parameters, number of valid hops and limb symmetry index (LSI) in 38 ACLR patients. Contact time parameters are presented as mean, standard deviation (SD), and coefficient of variation (CV) of contact time. Results: Intra-tester reliability was good to excellent for all contact time parameters. For discriminant validity, the mean and SD contact times of the OP leg were significantly longer than those of the NOP leg, although the difference was smaller than the SEM and MDC values. The number of valid jumps and CV contact time parameters were not significantly different. Isokinetic quadriceps strength (60°/s) was strongly correlated with mean contact time for both legs. However, psychological readiness was not correlated with any of the contact time parameters. Conclusions: Temporal parameters of the SHT measured on video analysis are valid and reliable parameters to assess the performance strategy of the SHT. The results should be interpreted with caution regarding the SEM and MDC values. Further studies are needed to measure criterion validity, inter-rater reliability, and responsiveness.

Reliability of Spatiotemporal Characteristics During Single-Legged Hop and Bilateral Drop Jump Tasks Using an Instrumented Pressure Walkway

Background

Single-legged hop tests have been widely used to assess performance-based outcomes after anterior cruciate ligament (ACL) reconstruction. Traditional single, triple, or 6-meter (6m) timed hop tests only measure distance or time as the principal variables, neglecting other variables, such as individual hop distances within a series of hops, flight time, and stance time. The development of portable instrumented pressure walkways has made it possible to collect parameters such as hop velocity, flight time, stance time, distance, and pressure outside of a laboratory setting. However, the reliability of instrumented pressure walkways in measuring spatial and temporal variables during single-legged hop tests is unknown. This study aimed to determine if the Zeno walkway can reliably measure spatiotemporal (ST) characteristics of hop tests.

Study Design

Cross-Sectional Study.

Methods

Individuals (n=38) in this cross-sectional study performed single, triple, and 6m hop tests on a pressure-sensitive Zeno walkway. Twenty-one participants completed follow-up testing between one and 14 days later. Intraclass correlation coefficients (ICC(3,k)) were used to assess test-retest reliability of ST variables. The accuracy of vertical jump height and 6m hop timing were also measured.

Results

All ST variables demonstrated excellent test-retest reliability (ICC > 0.86) with small minimal detectable change (MDC) values during single-legged hop tests. Six-meter hop time and jump height during a bilateral drop jump were also accurately measured by the walkway.

Conclusion

An instrumented pressure walkway is a novel tool to reliably assess non-traditional parameters of clinically relevant hop and jump tests such as flight time, stance time, and jump height after lower extremity injury, surgery, and rehabilitation.

Level of Evidence

3b.

Previous Knee Surgery, Anteromedial Portal Drilling, Quadriceps Tendon Autograft, and Meniscal Involvement Associated With Delayed Return to Sport After Anterior Cruciate Ligament Reconstruction in Amateur Athletes

Purpose

To identify prognostic factors associated with a delayed return-to-sport (RTS) time in amateur athletes who return to full participation after a primary isolated anterior cruciate ligament (ACL) reconstruction.

Methods

A retrospective review was performed among athletes who underwent ACL reconstruction between October 2014 and October 2021. Inclusion criteria were any amateur athletes with an ACL reconstruction who had a documented RTS and greater than 1-year follow-up. Nonathletes, those with multiligamentous knee injury, and those missing documented RTS timelines were excluded. RTS was defined as participation in athletics at a level equivalent to or greater than the preinjury level participation. Demographic and prognostic factors, including previous knee surgery, meniscal involvement, level of participation, surgical approach, and graft type, were recorded along with RTS time and analyzed via Poisson regression.

Results

In total, 91 athletes, average age 18.8 (± 6.7) years, who underwent ACL reconstruction at a single institution from 2014 to 2021 were identified with an average follow-up time of 4.6 (± 2.5) years (range 1.1, 9.0). Meniscal involvement (1.11; 95% confidence interval [CI] 1.08-1.15, P < .001) and previous knee surgery (1.43; 95% CI 1.29-1.58; P < .001) were related to a delayed RTS. Quadriceps tendon and bone-patellar tendon-bone autografts, as well as allograft, showed a significant association with a longer RTS time when compared with hamstring autograft (1.16, 95% CI 1.13-1.20, P < .001; 1.04, 95% CI 1.01-1.07, P = .020; 1.11, 95% CI 1.03-1.19, P = .004, respectively), as did anteromedial portal drilling, when compared with the outside in approach for femoral drilling (1.19, 95% CI 1.16-1.23, P < .001).

Conclusions

Previous knee surgery, anteromedial femoral drilling, quadriceps tendon autograft, and meniscus tear were most associated with a delayed timeline for RTS among young athletes who were able to return.

Level of Evidence

Level IV, prognostic case series.

A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens

Purpose

To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule.

Methods

Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci).

Results

In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root).

Conclusions

In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age.

Clinical Relevance

The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.

Effect of Sex and Lateral Ankle Sprain History on Dorsiflexion Range Of Motion Asymmetry During the Weight Bearing Lunge Test

Background

Reduced dorsiflexion range of motion (DFROM) which is commonly seen following lateral ankle sprain (LAS) has the potential to influence lower extremity biomechanics which have been linked to increased injury risk in the female athlete. Current research on the effect of sex and LAS history on DFROM is limited.

Hypothesis/Purpose

This study had three aims 1) to determine the effect of sex, leg dominance and LAS history on DFROM, 2) to determine the effect of sex and LAS history on magnitude of DFROM symmetry and 3) to examine the association of sex on direction (whether dominant or non-dominant limb had the higher DFROM) of symmetry.

Study Design

Cross-Sectional Study.

Methods

DFROM was measured bilaterally in 105 recreational athletes all participating in multidirectional sports using the tape measurement method during the weight bearing lunge test (WBLT). A mean of three measurements was used for analysis. A 3-way mixed ANOVA was carried out to determine the interaction between sex, LAS history and leg dominance on DFROM and a 2-way ANOVA for the effect of sex and LAS history on asymmetry. A chi-square test was used to determine the association of sex and direction of asymmetry.

Results

The results indicate no significant effect of sex, LAS history, and leg dominance on DFROM (p=0.65). Main effects were significant for sex and LAS on DFROM. The mean asymmetry for all participants was reported as 12.25±14.76cm. No significant effect of sex and LAS history on magnitude of asymmetry was reported. There was a significant association of sex and direction of asymmetry (χ2(1) = 11.26, p = 0.00). Sixty-five-point two percent of males were shown to have higher DFROM of their non-dominant limb compared to 75% of females who were higher in their dominant limb.

Conclusion

Findings from this study suggest that DFROM is affected by sex and LAS history. While females have increased DFROM compared to males, those with LAS history are more likely to have a decreased DFROM on the involved side. The results also indicate that interlimb asymmetries in DFROM are present in athletes, therefore practitioners should exercise caution when using bilateral comparisons in injury and return to play assessments.

Level of Evidence

2b.

Transphyseal ACL reconstruction and tenodesis in skeletally immature patients demonstrates encouraging clinical scores, without growth disturbance, excessive laxity or re-injury

Purpose

Paediatric patients demonstrate high re-rupture rates after anterior cruciate ligament reconstruction (ACLR), with numerous surgical techniques proposed to deal with this challenging cohort. This study investigated the early clinical outcomes, complications, return to sport (RTS) and re-rupture rates up until 2-years post-surgery in paediatric patients presenting with open growth plates undergoing transphyseal ACLR that was combined with an extra-articular tenodesis (LET).

Methods

Between October 2017 and September 2020, 20 skeletally immature patients were consecutively recruited and underwent transphyseal ACLR and LET. Patient reported outcome measures (PROMs), KT-1000 laxity, knee range of motion (ROM), maximal isokinetic knee torque and a 3-hop battery were assessed at 6-, 12- and 24-months. Limb Symmetry Indices (LSIs), RTS rates, complications, re-ruptures and re-operations were reviewed.

Results

All PROMs improved (p < 0.05). No change (p = 0.903) in laxity between limbs was seen, while 18 patients (90%) demonstrated normal (<3 mm) or near normal (3-5 mm) laxity differences. Peak knee flexion ROM improved over time (p = 0.028), while LSIs for knee extensor strength (p < 0.001), the single (p = 0.002) and triple crossover (p = 0.038) hop tests improved. At 24 months, 18 patients (90%) were participating in their pre-injury pivoting sport activities. No complications, growth disturbances, re-injuries or subsequent surgeries were observed.

Conclusions

Transphyseal ACLR combined with LET, undertaken in skeletally immature paediatric patients, demonstrated high scoring PROMs, physical performance and RTS overall, without evidence of growth disturbance or excessive graft laxity. No re-injuries have been observed at this time with ongoing review required in this high-risk cohort.

The Addition of the Gracilis Tendon to a Semitendinosus Tendon Autograft Is Not Associated With Knee Muscle Strength, Subjective Knee Function, or Revision Surgery After Anterior Cruciate Ligament Reconstruction

PURPOSE

To evaluate and compare isokinetic knee muscle (extension and flexion) strength, single-leg hop (SLH) test performance, anterior knee laxity, subjective knee function, and the 2-year revision surgery risk between patients who underwent anterior cruciate ligament reconstruction (ACLR) with semitendinosus tendon (ST) autografts and patients who underwent ACLR with ST and gracilis tendon (ST-G) autografts.

METHODS

We identified patients aged 16 years or older who underwent primary ACLR with hamstring tendon autografts at our institution from January 2005 to December 2020 and had no associated ligament injuries. Isokinetic knee muscle strength and SLH test performance were assessed 6 months postoperatively. Anterior knee laxity (KT-1000 arthrometer, 134 N) was assessed preoperatively and 6 months postoperatively. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and 1 and 2 years postoperatively. Patients who underwent revision ACLR at any institution in Sweden within 2 years of primary surgery were identified through the Swedish National Knee Ligament Registry.

RESULTS

A total of 6,974 patients (5,479 with ST and 1,495 with ST-G) were included. There were no significant differences in extension and flexion strength or SLH test performance between the groups. Preoperatively, there was no significant difference in knee laxity between the ST and ST-G groups. Postoperatively, the ST-G group had significantly increased mean side-to-side (STS) laxity (2.1 ± 2.3 mm vs 1.7 ± 2.2 mm, P < .001) and showed a trend toward increased STS laxity according to the International Knee Documentation Committee form, with significantly fewer patients with STS laxity of 2 mm or less (58.4% vs 65.8%) and significantly more patients with STS laxity between 3 and 5 mm (35.0% vs 29.9%) or greater than 5 mm (6.6% vs 4.3%) (P < .001). The only significant difference in subjective knee function was for the KOOS Quality of Life subscale score in favor of the ST group preoperatively (37.3 ± 21.4 vs 35.1 ± 19.9, P = .001). No other significant differences between the groups were found preoperatively and 1 and 2 years postoperatively for any of the KOOS subscales. The overall revision ACLR rate within 2 years of primary surgery was 2.0% (138 of 6,974 patients). The revision ACLR risk in the ST-G group (1.7%, 25 of 1,495 patients) was not significantly different from that in the ST group (2.1%, 113 of 5,479 patients) (hazard ratio, 0.80; 95% confidence interval, 0.50-1.24; P = .32).

CONCLUSIONS

The addition of the gracilis tendon to an ST autograft was not associated with knee muscle strength, SLH test performance, subjective knee function, or the risk of revision surgery after ACLR.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Reduction in re-rupture rates following implementation of return-to-sport testing after anterior cruciate ligament reconstruction in 313 patients with a mean follow-up of 50 months

OBJECTIVES

The objective of this study was to assess the mid-term effectiveness of a return to sport (RTS) test in relation to preventing anterior cruciate ligament (ACL) re-rupture and contralateral ACL injury following ACL reconstruction (ACLR). Furthermore, this study aimed to assess the timing of passing a, RTS-test after surgery, and the effect age has on RTS outcomes.

METHODS

Patients undergoing ACLR between August 2014 and December 2018 took an RTS-test following rehabilitation. The RTS-test consisted of the Anterior Cruciate Ligament Return to Sport After Injury Scale, a single-leg hop, a single-leg triple hop, a single-leg triple cross-over hop, a box-drop vertical jump down, a single-leg 4-rep max-incline leg press, and a modified agility T test. RTS-passing criteria were ≥90% limb symmetry index in addition to defined takeoff and landing parameters. Mid-term review assessed sporting level, ACL re-injury, and contralateral ACL injury.

RESULTS

A total of 352 patients underwent RTS-testing, following ACLR with 313 (89%) contactable at follow-up, a mean of 50 months (standard deviation: 11.41, range: 28-76) after surgery. The re-rupture rate was 6.6% after passing the RTS-test and 10.3% following failure (p ​= ​0.24), representing a 36% reduction. Contralateral ACL injury rate after surgery was 6% and was 19% lower in those passing the RTS test. The mean age of patients passing their first RTS-test was significantly higher than that of those who failed (p ​= ​0.0027). Re-ruptures in those who passed the RTS test first time occurred late (>34 months), compared to those who failed first time, which all occurred early (<33 months) (p ​= ​0.0015). The mean age of re-rupture was significantly less than those who did not sustain a re-rupture (p ​= ​0.025).

CONCLUSION

Passing a RTS-test following ACLR reduces ACL re-rupture by 36.21% and contralateral ACL injury by 19.15% at mid-term follow-up. Younger patients are more likely to fail a RTS-test and are at higher risk of contralateral ACL rupture.

LEVEL III EVIDENCE

Anterior Cruciate Ligament Reconstruction Using Bone-Patellar Tendon-Bone Autograft With Lateral Compartment Meniscectomy or Chondroplasty Does Not Lead to Decreased Return to Sport and Activity Compared With No Lateral Pathology

Purpose

To investigate the influence of lateral meniscal and cartilage pathology on the outcome after anterior cruciate ligament (ACL) reconstruction in patients who participate in pivoting sports.

Methods

Using a single-surgeon patient registry, patients undergoing an anterior cruciate ligament reconstruction (ACLR) using bone-patellar tendon-bone autograft were evaluated with minimum 2-year patient reported outcomes evaluated using Marx, Tegner, Lysholm, and International Knee Documentation Committee scales. Patients were divided into 3 groups: isolated ACL surgery, ACLR with a partial lateral meniscectomy, or a ACLR with partial lateral meniscectomy and lateral compartment chondroplasty.

Results

A total of 98 patients met inclusion criteria. Using the isolated ACL reconstruction group as a control, we found that Marx scores were greater in patients who additionally underwent a partial lateral meniscectomy at 1 year (P = .016). There were no significant differences between the ACL-only group and the ACL with partial lateral meniscectomy and chondroplasty group. Within the partial meniscectomy cohort comparing the patients with red-white zone tears with the patients with white-white zone tear, we found there were no significant differences when compared with the ACL-only control. There were no significant differences appreciated between groups using the International Knee Documentation Committee, Lysholm, and Tegner scales.

Conclusions

ACL reconstruction using bone-patellar tendon-bone autograft with anteromedial portal drilling technique does not have any significant short-term (2-year outcome) differences in return to activity and patient-reported outcomes compared with if patients additionally have a partial lateral meniscectomy and/or lateral compartment chondroplasty. Additional partial lateral meniscectomy showed significantly greater Marx scores at 1 and 2 years' postoperatively.

Level of Evidence

Level III, retrospective cohort study.

Impact of Surgical Timing on Functional Outcomes after Anterior Cruciate Ligament Reconstruction

Objectives: Although acute anterior cruciate ligament reconstruction (ACLR) is often avoided because of postoperative joint stiffness, delayed ACLR can lead to a longer recovery time and can have a negative impact on physical function due to detraining. This study aimed to determine the effects of acute ACLR on postoperative outcomes, including muscle strength, performance, and return to sports. Methods: A total of 110 patients who underwent anatomical ACLR using hamstring autografts were included in this study and were divided into three groups: acute (ACLR performed within 2 weeks after ACL injury), 2-6 weeks (ACLR performed between 2 and 6 weeks after injury), and 6-12 weeks (ACLR performed between 6 and 12 weeks after injury). Several parameters were evaluated, including range of motion, knee joint stability, isokinetic knee strength, performance, and return to sports. Results: No significant differences were found in the range of motion or knee joint stability between the groups. The acute group exhibited significantly greater quadriceps strength at 3 months postoperatively than the other groups (p < 0.05). The single-leg hop test showed that 66.7%, 38.7%, and 33.3% of the patients in the acute, 2-6 weeks, and 6-12 weeks groups, respectively, recovered to an LSI of 90% or greater (p = 0.09, Cramer's V = 0.27). All patients in the acute group were able to return to sports (p = 0.14; Cramer's V = 0.28). Conclusions: Acute ACLR is advantageous for the early recovery of strength and performance without adverse events. Acute ACLR may shorten the time spent away from sports activities.

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

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

Rehabilitation and return-to-sport after anterior cruciate ligament injury and reconstruction: Exploring physical therapists' approaches in Argentina

OBJECTIVES

To investigate the current clinical practice regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Cross-sectional design. Online survey.

SETTING

Survey platform.

PARTICIPANTS

Argentinian physical therapists (PTs).

OUTCOME MEASURES

The survey consisted of a combination of 39 open- and closed-ended questions, divided across 3 sections: (1) demographic and professional information, (2) clinical practice and rehabilitation strategies, and (3) return-to-running (RTR) and RTS.

RESULTS

A total of 619 PTs completed the survey. Considerable variability was observed in preoperative rehabilitation, criteria used for rehabilitation progression and RTS decision-making criteria used by PTs. From the total surveyed, 336 (54.3%) carried out RTS assessment in their clinical practice. Most of PTs (53.3%) use visual estimation to assess knee range of motion. Only 20% of the PTs reported incorporating patient-reported outcome measures in their decision-making. From PTs who use strength assessment as a criterion of RTS (68.8%), 16.6% extrapolate this from jump tests and 15.3% use manual muscle testing. Less than the 50% of the PTs recommended nine months or more to allow patients to RTS.

CONCLUSIONS

Current rehabilitation practices of Argentinian PTs following ACLR are largely variable and not aligned with current evidence and scientific guidelines. To achieve better rehabilitation and RTS practices better knowledge dissemination and implementation are required.

Late-stage rehabilitation after anterior cruciate ligament reconstruction: A multicentre randomised controlled trial (PReP)

BACKGROUND

At the completion of formal rehabilitation after anterior cruciate ligament reconstruction, functional capacity is only restored in a small proportion of affected individuals. Therefore, the end of formal rehabilitation is not the end of functional rehabilitation.

OBJECTIVE

To compare adherence to and effectiveness of a late-stage rehabilitation programme with usual care after anterior cruciate ligament (ACL) reconstruction.

METHODS

This prospective, double-blind, multicentre, parallel group, randomised controlled trial, included people aged 18 to 35 years after formal rehabilitation completion (mean [SD] 241 [92] days post-reconstruction). Participants were block-randomised to a 5-month neuromuscular performance intervention (Stop-X group) or usual care (medically prescribed standard physiotherapy, individual formal rehabilitation, home-exercises). All outcomes were measured once/month. Primary outcome was the normalised knee separation distance on landing after drop jump. Baseline-adjusted linear mixed models were calculated.

RESULTS

In total, 112 participants (Stop-X: 57; Usual care: 55,) were analysed. Initially, mean (SD) intervention frequency (units/week) was higher in the Stop-X than the Usual care group: 2.65 (0.96) versus 2.48 (1.14) units/week in the first and 2.28 (1.02) versus 2.14 (1.31) units/week in the second month. No between-group*time(*baseline)-differences were found for the primary outcome. Between-group*time-effects favoured the Stop-X-group at 2 months (fewer self-reported knee problems during sport, KOOS-SPORT) (estimate = 64.3, 95 % CI 24.4-104.3 for the Stop-X), more confidence to return to sport (ACL-RSI) (62.4, 10.7-114.2), fewer pain-associated knee problems (KOOS-PAIN) (82.8, 36.0-129.6), improved everyday activity abilities (KOOS-ADL) (71.1, 6.4-135.7), and improved limb symmetry index in the front hop for distance at 3 and 4 months (0.34, 0.10-0.57; 0.31, 0.08-0.54). No between-group*time-effects occurred for kinesiophobia, symptom-associated knee problems or balance hops performance. At the end of the intervention, 79 % of the Stop-X and 70 % of the Usual care participants (p < 0.05) had successfully returned to their pre-injury sport type and level.

CONCLUSIONS

The Stop-X intervention was slightly superior to usual care as part of late-stage rehabilitation after ACL-reconstruction. The small benefit might justify its use after formal rehabilitation completion.

Injury prevention in Brazilian women's football: Perceptions of physiotherapists and practices within elite clubs

OBJECTIVES

To describe the perceptions of physiotherapists and the injury prevention practices implemented within elite women's football clubs in Brazil.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PARTICIPANTS

Head physiotherapists from 32 Brazilian elite clubs.

MAIN OUTCOME MEASURES

Structured questionnaire.

RESULTS

Physiotherapists identified ACL rupture as the primary target for prevention. The top-five perceived injury risk factors included 'early return to sport after injury', 'workload too high', 'previous injury', 'poor sleep/rest', and 'muscle strength/power deficit'. 'Adoption of return to sport criteria' was almost unanimously recognized as a very important preventive strategy. 'Poor infrastructure' was elected as the main barrier to implementing prevention programs. From a practical standpoint, at least two-third of clubs implemented multi-component exercise interventions for injury prevention. These interventions typically encompassed flexibility/mobility, balance/proprioception, lumbo-pelvic stability, and agility exercises, alongside exposure to sprinting. Strength training routines typically included traditional, functional, and eccentric exercises. Most teams also employed other prevention strategies, including adoption of return to sport criteria, internal workload monitoring, post-exercise recovery modalities, preseason risk factor screening, and application of rigid strapping tapes.

CONCLUSIONS

This study provided unprecedented insights into the physiotherapists' perceptions and injury prevention practices implemented within elite women's football clubs.

Comparison of physical therapy utilization, timing of return-to-sport test completion, and hop test performance by age and between sexes in youth athletes after anterior cruciate ligament reconstruction

OBJECTIVE

To compare physical therapy (PT) utilization, timing of return-to-sport (RTS) test and hop test performance by age and between sexes in youth after anterior cruciate ligament reconstruction (ACLR).

DESIGN

Multicenter retrospective cohort.

METHODS

A retrospective review of adolescents after primary ACLR was conducted. Participants completed return-to-sport (RTS) tests including single-legged hop testing. PT frequency, average weekly visits, and timing of RTS test were calculated. T-tests assessed the effect of age and sex on average weekly PT visits and multivariable logistic regressions assessed odds of passing hop tests.

RESULTS

289 participants were included (15.7 ± 1.9 years). There was no difference in average weekly PT visits (p = 0.321) or time to RTS test (p = 0.162) by age. There were significant differences in average weekly PT visits (p = 0.047) and mean time from surgery to RTS test (p = 0.048) between sexes with small effect sizes (d = 0.24 and d = 0.21, respectively). Age and sex had no effect on odds of passing hop tests (OR, 1.29; 95% CI, 0.71-2.35 and OR, 0.79; 95%CI, 0.43-1.45, respectively).

CONCLUSION

In a youth cohort, age and sex may have no clinically important effect on PT visit utilization, timing of RTS test or hop test performance.

Nurse-Assisted Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction

Despite significant advancements in surgical instruments and operation skills, short- and long-term outcomes following anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, as many patients fail to return to their pre-injury level of sports. Inadequate ACL rehabilitation is the primary cause of poor outcomes. Nurses have become a crucial element in the rehabilitation process. Although there is no consensus regarding the optimal post-operative rehabilitation protocols, restoring muscle strength and neuromuscular control are consistently the primary goals. This literature review presents nurse-assisted rehabilitation protocols aiming at improving muscle strength and neuromuscular control. The review discusses postoperative rehabilitation, including home-based and supervised rehabilitation, open and closed kinetic chain exercises, eccentric and concentric training, blood flow restriction training, and plyometric training. Each training protocol has its benefits and drawbacks, and should be used cautiously in specific stages of rehabilitation. Neuromuscular training, such as neuromuscular electrical stimulation, neuromuscular control exercises, and vibration therapy, is considered crucial in rehabilitation.

No Association Between Injury-Related Fear and Isokinetic Quadriceps Strength in Individuals With a History of Anterior Cruciate Ligament Reconstruction

CONTEXT

Injury-related fear and quadriceps strength are independently associated with secondary anterior cruciate ligament (ACL) injury risk. It is not known whether injury-related fear and quadriceps strength are associated, despite their individual predictive capabilities of secondary ACL injury. The purpose of this study was to examine the association between injury-related fear and quadriceps strength in individuals at least 1 year after ACL reconstruction (ACLR).

DESIGN

Cross-sectional study.

METHODS

Forty participants between the ages of 18 and 35 years at least 1 year post unilateral primary ACLR. Participants completed the Tampa Scale of Kinesiophobia-11 (TSK-11) and a standard isokinetic quadriceps strength assessment using the Biodex Isokinetic Dynamometer. Pearson Product-Moment correlations were used to examine the linear association between the TSK-11 scores and peak torque (in nanometers per kilogram) for each limb and between the TSK-11 scores and limb symmetry indices for each limb. Pearson Product-Moment correlation coefficients (r) were interpreted as very high (.90-1.00), high (.70-.90), moderate (.50-.70), low (.30-.50), and no correlation (.00-.30).

RESULTS

The average TSK-11 score was 18.2 (5.3), average ACLR peak quadriceps torque was 1.9 (0.50) N·m/kg, average contralateral peak quadriceps torque was 2.3 (0.48) N·m/kg, and average limb symmetry index was 85.3% (12.6%). There was no statistically significant correlation between the TSK-11 and peak quadriceps torque on the ACLR limb (r = .12, P = .46), the TSK-11 and contralateral limb (r = .29, P = .07), or the TSK-11 and limb symmetry index (r = -.18, P = .27).

CONCLUSIONS

There was no association between kinesiophobia and peak isokinetic quadriceps strength in individuals at least 1 year post-ACLR. Both factors, independently, have been shown to influence risk of secondary injury in patients after ACLR.

Association between passing return-to-sport testing and re-injury risk in patients after anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis

Background

Inconsistent results have been obtained regarding the association between return-to-sport (RTS) testing and the risk of subsequent re-injury following anterior cruciate ligament reconstruction (ACLR). We therefore conducted a systematic review and meta-analysis to assess the potential association between passing of RTS and the risk of re-injury for patients after ACLR.

Methods

This meta-analysis was registered in INPLASY with the registration number INPLASY202360027. The electronic databases MedLine, EmBase, and the Cochrane library were systematically searched to identify eligible studies from their inception up to September 2023. The investigated outcomes included knee injury, secondary ACL, contralateral ACL injury, and graft rupture. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the random-effects model.

Results

A total number of nine studies involving 1410 individuals were selected for the final quantitative analysis. We noted that passing RTS test was not associated with the risk of subsequent knee injury (OR: 0.95; 95% CI: 0.28-3.21; P = 0.929), secondary ACL injury (OR: 0.98; 95% CI: 0.55-1.75; P = 0.945), and contralateral ACL injury (OR: 1.53; 95% CI: 0.63-3.71; P = 0.347). However, the risk of graft rupture was significantly reduced (OR: 0.49; 95% CI: 0.33-0.75; P = 0.001).

Conclusions

This study found that passing RTS test was not associated with the risk of subsequent knee injury, secondary ACL injury, and contralateral ACL injury, while it was associated with a lower risk of graft rupture. Thus, it is recommended that patients after ACLR pass an RTS test in clinical settings.

Delaying anterior cruciate ligament reconstruction for more than 3 or 6 months results in lower risk of revision surgery

BACKGROUND

The objective of this study is to investigate the risk of revision surgery when delaying anterior cruciate ligament reconstruction (ACLR) past 3 months or 6 months after injury.

MATERIALS AND METHODS

A total of 30,280 patients with isolated ACLR were identified in the Danish Knee Ligament Reconstruction Registry and divided into four groups; ACLR < 3 months, > 3 months, < 6 months, or > 6 months after injury. Primary outcome was revision surgery and secondary outcome were objective and subjective clinical outcome. The 2 year relative risk, crude, and adjusted hazard ratio (HR) were calculated.

RESULTS

Comparing ACLR < 3 months to ACLR > 3 months of injury the 2 year relative risk of revision surgery was found to be 1.81 (95% CI 1.46-2.23; P < 0.001) with an adjusted hazard ratio (HR) of 1.27 (95% CI 1.12-1.44; P < 0.001). Comparing ACLR < 6 months to ACLR > 6 months of injury the 2 year relative risk of revision surgery was found to be 1.61 (95% CI 1.34-1.92; P < 0.001) with an adjusted HR of 1.27 (95% CI 1.15-1.40; P < 0.001).

CONCLUSION

The risk of revision ACLR surgery was found to be increased when ACLR was performed within 3 months or 6 months of injury compared with later surgery. The 1 year postoperative objective knee laxity and the subjective patient-related outcome was found to be without a clinically significant difference; however, those with early ACLR (< 3 months or < 6 months) were found to have a higher activity level 1 year postoperatively. The information about increased risk of revision when having early surgery should be informed to patients when deciding timing of ACLR treatment.

LEVEL OF EVIDENCE

II.

Comparative Effectiveness of Supervised and Home-Based Rehabilitation after Anterior Cruciate Ligament Reconstruction in Competitive Athletes

Background: After the increasingly common anterior cruciate ligament reconstruction (ACLR) procedure in competitive athletes, rehabilitation is crucial for facilitating a timely return to sports (RTS) and preventing re-injury. This pilot study investigates the patient-reported outcomes of postoperative rehabilitation in competitive athletes, comparing supervised rehabilitation (SVR) and home-based rehabilitation (HBR). Methods: After ACLR, 60 (out of 74 screened) athletes were recruited and equally divided into HBR and SVR groups using non-probability convenience sampling, with each group comprising 15 males and 15 females. The rehabilitation outcomes in the respective groups were evaluated at 8 months using measures (Tegner Activity Scale [TAS], International Knee Documentation Committee subjective knee form [IKDC-SKF], ACL Return to Sport after Injury [ACL-RSI]) and objective parameters (isometric muscle strength, hamstring/quadricep asymmetry). RTS was evaluated at 9 months, with ACL re-injury rates recorded approximately 6 months post-RTS. Results: Both groups exhibited decreased TAS scores (HBR: 8 to 6, SVR: 8 to 7), with the SVR group demonstrating superior postoperative IKDC-SKF scores (81.82 vs. 68.43) and lower ACL-RSI scores (49.46 vs. 55.25). Isometric and isokinetic muscle strength, along with asymmetry values, was higher in the SVR group 8 months post-ACLR (p < 0.05). The SVR group showed a higher RTS rate to the same level (76.6% vs. 53.3%), while the re-injury rate was the same in both the rehabilitation groups (3.3%). Conclusions: Although both rehabilitation approaches yielded comparable outcomes, SVR may demonstrate some superior biomechanical improvements in athletes, resulting in a higher RTS rate. However, the psychological outcomes and re-injury rates did not significantly differ between the groups, emphasizing the need to address individual psychological needs during rehabilitation. Further investigation is recommended with a larger sample size to address the differences of gender among competitive athletes.

A study regarding the anterior cruciate ligament remnant: Differences in balance and postural control between remnant-preserving and remnant-non-preserving patients

INTRODUCTION

The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. However, quantitative studies on evaluate the postural control influence resulted from the ACL remnant preservation or not are scarce. The aim of this study is to evaluate the postural control of patients submitted to ACL reconstruction with and without preservation of the injured remnant in pre and postoperative periods.

METHODS

Eighteen patients underwent ACL reconstruction and separated into 2 groups according to the preservation or not of the remnant: (I) submitted to ACL reconstruction with preservation of the remnant (10 patients); (II) submitted to ACL reconstruction without preservation of the remnant (8 patients). They were assessed using the Lysholm score and force plate, which evaluated the patient's postural stability for remnant and non-remnant preservation in ACL reconstruction surgery.

RESULTS

Group I showed statistically significant subjective and objective improvements, both at 3 and 6 months. Additionally, improvement of the Lysholm test at 6 months in Group II was also statistically significant. Furthermore, the results of the Friedman test for the VCOP and VY variables of Group I, with support of the injured side in the force plate, showed a statistically significant difference both for pre and postoperative period at 3 months, compared to the 6-month postoperative period. The variables EAC and VX were statistically different for Group II, considering the preoperative period, 3 and 6 months postoperatively.

CONCLUSION

Preserving the ACL remnant in patients with ACL injuries has a positive impact on postural stability during recovery.

Are lower limb symmetry and self-reported symptoms associated with functional and neuromuscular outcomes in Brazilian adults with anterior cruciate ligament reconstruction? A cross-sectional study

INTRODUCTION

After anterior cruciate ligament (ACL) reconstruction, determining readiness to return to participation is challenging. The understanding of which neuromuscular performance parameters are associated with limb symmetry and self-reported symptoms may be useful to improve monitoring the rehabilitation towards adequate decision-making to return.

OBJECTIVES

To compare the ACL-operated and injury-free lower limbs regarding functional performance; and to investigate whether lower limb strength and functional performance are associated with self-reported symptoms and functional lower limb symmetry.

METHOD

Thirty-four participants were included. Functional performance was assessed by using the Y-Balance test, Single-leg Hop, and Functional Movement Screen. An isokinetic dynamometer was used to evaluate the strength levels in open and closed kinetic chains. The functional lower limb symmetry was calculated considering the single-leg hop test results for each lower limb.

RESULTS

There were no differences in dynamic balance (Y-Balance) between the operated and injury-free limbs. The operated limb presented a worst performance in the single-leg hop. Self-reported symptoms prevalence and lower limb symmetry were associated with knee extension strength and functional performance (Y-Balance).

CONCLUSION

Individuals submitted to ACL-reconstruction presented worse functional performance in the operated limb compared to the injury-free limb. Both knee strength and dynamic balance were associated with limb symmetry and self-reported symptoms.

Risk factors of knee reinjury after anterior cruciate ligament reconstruction

PURPOSE

This study aimed to investigate whether the return to level I sports, concomitant injuries, foot-related problems, and other factors would increase the risk of knee reinjury after anterior cruciate ligament reconstruction (ACLR).

METHODS

This study used a prospective cohort study design. Online enrolment from August 2018 to January 2019 in ACL Community Indonesia recruited 148 patients who had undergone ACLR less than one month prior to injury. Knee injury occurrence after ACLR was diagnosed through a physical examination and positive MRI or arthroscopic findings.

RESULTS

During the study, 55 knee reinjuries occurred. The proportional hazards model analysis revealed that the risk of knee reinjury at 12 and 24 months for patients who returned to level I sports (hazards ratio (HR)=3.17 and HR=3.90, respectively) was significantly higher than that of the patients who did not return to sports and that the risk for those who returned to level II/III sports did not significantly increase at 12 or 24 months. Patients with concomitant meniscus injury had a significantly higher risk of knee reinjury at 12 and 24 months (HR=3.33 and HR=2.25, respectively) than those without, and the risk of knee reinjury for patients with concomitant posterior cruciate ligament injury was significantly higher at 12 months (HR=3.05) but not at 24 months. Fewer knee symptoms after ACLR were significantly associated with a lower risk of knee reinjury (HR=0.98) at 12 and 24 months.

CONCLUSIONS

The return to level I sports, concomitant meniscus and posterior cruciate ligament injury, and knee symptoms after ACLR may increase the risk of knee reinjury for post-ACLR patients.

Isokinetic Testing: Why it is More Important Today than Ever

Isokinetics is a proven method to train and objectively assess the capability of muscle groups, particularly at the knee. The current re-injury rates and less than optimal return to sport percentages seen following anterior cruciate ligament surgery highlights the need for greater focus on what tests and methods are used to make these critical decisions. Isokinetics remains the best single method to objectively determine dynamic muscle strength, power, rate of force development and endurance. These factors make it well-suited to play a crucial role in influencing the appropriate patient progression through a rehabilitation program and assisting in determining return to play readiness following injury or surgery. In this article we will discuss why we believe isokinetics is a useful and necessary testing method, and elucidate testing parameters and goals used during knee extension/flexion assessment.

Feasibility, Reliability, and Validity of the Modified Forward Hop Test After Anterior Cruciate Ligament Reconstruction: Double- Instead of Single-legged Landing is Reliable and Results in Greater Hopping Distance

OBJECTIVE

To investigate the feasibility, reliability, and validity of the Modified forward hop (MFH) test in participants after ACL reconstruction (ACLR).

DESIGN

Reliability study.

SETTING

Assessments were administered at different clinical locations in Germany and Switzerland by the same 2 investigators.

PARTICIPANTS

Forty-eight active individuals participated in this study (N=48).

MAIN OUTCOME MEASURES

The participants performed MFHs and Forward hops for distance in a predetermined order. The feasibility of the MFH was quantified with proportions of successfully executed attempts and Pearson's χ2 test. Its reliability was estimated using intraclass correlation coefficient (ICC) and standard error of measurement (SEM). Test validity was explored using Pearson's product moment correlation analyses.

RESULTS

Fewer failed attempts were recorded among the participants (age: 30 [Standard deviation 11] years; 22 women, 26 (13) months post-surgery) when compared with the Forward hop for distance test (25/288 trials; 9% vs 72/288 trials; 25%). Within-session ICC values were excellent (>0.95) for both types of Forward hop tests, independent of the side examined. The SEM values were comparable between the Modified (injured: 5.6 cm, uninjured: 5.9 cm) and the classic Forward hop (injured: 4.3 cm, uninjured: 7.2 cm).

CONCLUSION

The MFH is a feasible, reliable, and valid tool for judging neuromuscular performance after ACLR. If the aim of a hop for distance incorporates enhanced perceived or real landing safety, landing on both feet should be used.

Anterior cruciate ligament: A brief narrative review of main risk factors for injury and re-injury

Anterior cruciate ligament (ACL) injury is one of the main injuries in professional and amateur athletes of different sports. Hundreds of thousands of ACL ruptures occurs annually, and only 55% of the athletes return to competitive level, with a 15 times higher chance of suffering a second injury. 60% of these injuries occur without physical contact and since they occur in the acute process, they can cause joint effusion, muscle weakness and functional incapacity. In the long term, they can contribute to a premature process of osteoarthritis. This narrative review is of particular interest for clinicians, practitioners, coaches and athletes to understand the main factors that contribute to an injury and/or re-injury and thus, to optimize their training to reduce and/or prevent the risk of injury and/or reinjury of ACL. Therefore, we aimed reports a narrative overview of the literature surrounding communication and explore through a theoretical review, the main risk factors for an ACL injury and/or re-injury, as well as bringing practical and correct methods of training applications. The lack of theoretical/practical knowledge on the part of rehabilitation and/or training professionals may impair the treatment of an athlete and/or student. High-quality research that can testing different training methods approaches in randomized controlled trials is needed.

Return to Sport, Re-injury and Performance After the Anterior Cruciate Ligament Reconstruction: Evaluating the Role of International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) Scoring Systems

Introduction Anterior cruciate ligament (ACL) tears are common injuries that can considerably impact an individual's quality of life and athletic performance. In these cases, surgical reconstruction of the ligament can be considered to restore stability to the knee. This study aims to investigate the time taken for individuals to return to sport post-ACL reconstruction, assess the rate of re-injury and evaluate the reliability of the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) scoring systems in predicting a return to sport at the pre-injury level. Methods In this retrospective study, a total of 104 patients who underwent ACL reconstruction between January 2016 and December 2022 by one surgical team at Mater Dei Hospital, Malta were evaluated using a self-administered questionnaire. The questionnaire was based on different components including the sport practised at the time of injury, sport engagement classification, return to sport, the ability to return to pre-injury levels of performance and re-injury. The participants then had to fill in IKDC and KOOS evaluation forms. Results In this study, 73% (n=76) of individuals successfully returned to sport after ACL reconstruction, with no significant difference being found between professional and recreational athletes (Chi-squared=0.00455, p=0.95). After reconstruction, 31.7% (n=33) of participants experienced an ipsilateral or contralateral ACL tear, with those returning to sport within six months showing a fivefold increase in re-injury risk compared to individuals who returned at eight or 12 months, suggesting a significant association between return duration and re-injury. The relationship between scoring systems and return to sport at the pre-injury level of performance was analysed using binary logistic regression, revealing that achieving scores of 85.6 or higher in IKDC or 89 or higher in KOOS meant having a 95% probability of returning to sport at the pre-injury level. Conclusions By considering these scoring systems with other post-operative criteria, clinicians can offer a more customised rehabilitation plan tailored to each patient who undergoes ACL reconstruction.

Beware of the "Moving Target" - Uninvolved Limb Strength Increases to Exceed Preoperative Values During Rehabilitation After ACL Reconstruction in Male Professional and Recreational Athletes

OBJECTIVE: To describe the changes in quadriceps and hamstrings muscle strength in the uninvolved limb of male professional and recreational athletes during rehabilitation after anterior cruciate ligament reconstruction (ACLR) and compare to preoperative strength values. DESIGN: Prospective longitudinal study. METHODS: During rehabilitation, 665 participants who underwent unilateral ACLR performed a strength test preoperatively and every 6 weeks after surgery for up to 9 months. Isokinetic quadriceps and hamstrings strength of the uninvolved limb were measured at an angular velocity of 60°/s and normalized to body weight (N·m/kg). RESULTS: Quadriceps and hamstrings strength of the uninvolved limb gradually increased during rehabilitation until 6 months post-ACLR, and plateaued thereafter. Postoperative quadriceps' strength significantly exceeded preoperative values by 3 months for professional (2.99 N·m/kg; 95% confidence interval [CI]: 2.93, 3.04; P = .007) and by 6 months for recreational athletes (2.77 N·m/kg; 95% CI: 2.71, 2.83; P<.001), and hamstrings exceeded presurgery levels by 4.5 months (1.71 N·m/kg; 95% CI: 1.67, 1.74; P<.001 and 1.43 N·m/kg; 95% CI: 1.40, 1.46; P = .002, professional and recreational athletes respectively). CONCLUSION: In male professional and recreational athletes, uninvolved limb quadriceps and hamstrings strength gradually improved after ACLR, until 6 months after surgery. The uninvolved limb's strength may present as a "moving target" that requires consistent monitoring during rehabilitation. J Orthop Sports Phys Ther 2024;54(4):1-9. Epub 14 December 2023. doi:10.2519/jospt.2023.11961.

Sex differences in corticospinal excitability and quadriceps performance after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) ruptures result in lasting quadriceps dysfunction that contributes to secondary injury risk and development of osteoarthritis. There is evidence of persistent reduced nervous system drive (corticospinal excitability [CSE]) to the quadriceps and sex differences in both quadriceps performance and CSE post-ACL reconstruction (ACLR). The purposes of this study were to investigate the differences in CSE and quadriceps dysfunction after ACLR between sexes and relative to controls. Twenty subjects 4-9 months post-ACLR and 20 age, sex, and activity matched controls participated in this study. Quadriceps performance (peak torque, PT; rate of torque development from onset to 100 ms, RTD100; and RTD from 100 to 200ms, RTD200) and CSE (active motor threshold; slope of the stimulus response (SR) curve, SR curve slope) were measured using an isokinetic dynamometer (HUMAC NORM) and transcranial magnetic stimulation respectively. Significant group differences were found for SR curve slope, PT, RTD100, and RTD200 on the surgical limb. Males after ACLR had higher slopes (higher CSE) than females. Females after ACLR had worse surgical limb quadriceps PT than control males and slower RTD100 and RTD200 than control males and control females. Higher CSE in males after ACLR may point to a potentially adaptive neurological change in males post-ACLR and indicate greater need for novel interventions to address cortical drive in females after ACLR.

Establishing Normal Variances and Expectations for Quadriceps Limb Symmetry Index Benchmarks Based on Time from Surgery After Anterior Cruciate Ligament Reconstruction

The anticipated timeline for muscle strength as well as return to running and sports are some of the most common inquiries by patients undergoing anterior cruciate ligament reconstruction. Despite the popularity of this procedure, the answers to these inquiries are not well described in the literature. The purpose of this study was to evaluate the range of quadriceps strength percentage and function benchmarks at various points after anterior cruciate ligament reconstruction surgery based on sex, age, and graft.

Design

Observational Cohort Study.

Methods

Patients who underwent anterior cruciate ligament reconstruction (ACLR) were evaluated at various points after their surgery with handheld dynamometer assessments. Additional hop and balance testing was performed and patients were evaluated for clearance for running and sport via a physical therapist directed functional movement assessment (FMA). The progression of quadriceps symmetry throughout the postoperative period was examined with multi-level models, estimates of time to reach 70%, 80%, and 90% quadriceps symmetry were obtained from the fitted model.

Results

A total of 164 patients were evaluated. Patients either received bone-tendon-bone (BTB) autograft (n=118) or BTB allograft (n=46) for their ACL graft. Average age was 31.1 years-of-age (SD: 13.6). Males undergoing ACLR using BTB autograft (n=53) were able to achieve 80% quadriceps symmetry earlier than females (n=65) (5.7 months vs 7.1 months), were cleared to return to run sooner (5.6 months vs 6.8 months) and passed an FMA exam earlier (8.5 months vs 10 months). Males undergoing ACLR with allograft (n=13) were able to achieve 80% quadriceps symmetry earlier than females (n=33) (3.9 months vs 5.4 months) and were cleared to run sooner (4.5 months vs 5.8 months).

Conclusion

Patients undergoing BTB autograft obtain 80% quadriceps symmetry at an average of 5.7 months for males and 7.1 months for females. Individuals under the age of 25 obtain their quadriceps symmetry faster and are cleared to return to running faster than individuals over 25. Male sex is associated with decreased amount of time to obtain clearance for running and for full activity. Male sex is associated with decreased amount of time to regain quadriceps symmetry however this was not significant.

Level of Evidence

4 (Case series).

Association Between Psychological Readiness to Return to Sports at 3 Months Postoperatively and Risk of Second ACL Injury

Background

Psychological readiness to return to sports (RTS) has been associated with second anterior cruciate ligament (ACL) injury. However, this relationship is controversial because covariates such as anatomic and knee function characteristics have not been adequately considered.

Purpose/Hypothesis

To investigate whether psychological readiness in the early postoperative period can predict the occurrence of a second ACL injury within 24 months after primary ACL reconstruction (ACLR) using propensity score analysis. It was hypothesized that patients with high ACL-RSI after injury (ACL-RSI) scores at 3 months postoperatively would have a second ACL injury within the projected postoperative period.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 169 patients who underwent primary ACLR using hamstring tendon autografts between November 2017 and July 2021 and also underwent knee functional assessments at 3 months postoperatively. The ACL-RSI scale was used to assess psychological readiness for RTS. A second ACL injury was defined if ipsilateral or contralateral ACL injury was confirmed by examination within 24 months postoperatively. Based on a previous study showing that 65 was the highest cutoff value for the ACL-RSI score for RTS, we classified patients into 2 groups: those with high ACL-RSI scores (≥65; group H) and those with low ACL-RSI scores (<65; group L). We generated 1-to-1 matched pairs using propensity score analysis and used log-rank testing to compare the rate of second ACL injury between the 2 groups.

Results

More patients returned to any sports activities within 12 months in group H than in group L (90% vs 73%; P = .03). A second ACL injury within 24 months postoperatively was identified in 7% of patients (13/169). The rate of second ACL injury was significantly higher in group H than in group L (17.6% vs 3.4%; P = .001). In 43 matched pairs extracted using propensity scoring, the rate of second ACL injury was also higher in group H than in group L (18.6% vs 4.7%; P = .04).

Conclusion

Patients with a higher ACL-RSI score at 3 months exhibited a significantly higher incidence of second ACL injury within 24 months after primary ACLR.

Effects of Kinesio taping on lower limb biomechanical characteristics during the cutting maneuver in athletes after anterior cruciate ligament reconstruction

PURPOSE

To determine the effects of Kinesio taping (KT) on the biomechanical characteristics of the lower limbs during the 90° cutting maneuver in anterior cruciate ligament (ACL) reconstruction (ACLR) athletes.

METHOD

Eighteen ACLR athletes were recruited and subjected randomly to three taping conditions, KT, placebo taping (PT), and no taping (NT), followed by a 90° cutting test. A nine-camera infrared high-speed motion capture system (Vicon, T40, 200 Hz) was used to record the kinematic parameters of the lower limbs during the cutting maneuver, and a three-dimensional dynamometer (Kistler, 1000 Hz) was used to record the kinetic parameters of the lower limbs. A one-way repeated measures analysis of variance was conducted to compare the differences in the lower limb kinematic and kinetic characteristics of ACLR athletes subjected to these interventions.

RESULTS

During the landing phase, the knee valgus angle reduced significantly with KT than with NT (95% confidence interval = -1.399 to -0.154; P = 0.025), whereas no significant difference was observed between PT and NT (95% confidence interval = -1.251 to 0.217; P = 0.236). No significant differences were observed in the other kinematic variables among the three taping conditions (P > 0.05). During the landing phase, no significant differences in the kinetic variables were observed among the three taping conditions (P > 0.05).

CONCLUSIONS

Although KT does not improve the kinetic variables of athletes after ACLR during the 90° cutting maneuver, it reduces the knee valgus angle, which could reduce the risk of secondary ACL injury.

Evaluation of Strength and Functional Ability of Soccer Players Two Years After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

OBJECTIVES

This study examines the strength and functional capacity of active soccer players two years post anterior cruciate ligament reconstruction (ACLR).

METHODS

Sixteen players, two years post ACLR, participated. Isokinetic tests assessed Peak Torque (PT) for concentric and eccentric contractions, along with conventional (H/Qconv) and functional (H/Qfunc) H/Q ratios at various angular velocities. Functional ability was gauged through hop tests. Paired-Samples T Test compared PT and hop test values, as well as H/Qconv and H/Qfunc ratios between involved and non-involved limbs. Limb symmetry was evaluated using the Limb Symmetry Index (LSI).

RESULTS

After two years, participants exhibited significant differences in concentric PT between limbs. The non-involved limb demonstrated superior performance at isokinetic speeds. Eccentrically, PT for knee extensors and flexors showed no significant disparities between the operated and non-operated limbs across all velocities tested. Most participants did not achieve LSI 90-110% for knee extensors and flexors. No noteworthy distinctions were observed in H/Qconv, H/Qfunc, and hop tests between limbs. The majority met LSI 90-110% in hop tests, except in the 30-second side hop (37%).

CONCLUSIONS

Two years post ACLR, soccer players still manifest strength and functional deficits, heightening the risk of injury.

Better Safe Than Sorry? A Systematic Review with Meta-analysis on Time to Return to Sport After ACL Reconstruction as a Risk Factor for Second ACL Injury

OBJECTIVE: To compare the time to return to sport (RTS) between patients who did and did not suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Cochrane Library, Embase, Medline, AMED, and PEDro databases were searched in August 2021 and again in November 2022. STUDY SELECTION CRITERIA: Clinical studies reporting time to RTS after ACL reconstruction and second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data (time [months] and proportions [%]), with random-effects meta-analyses. Pooled estimates were summarized in forest plots. A qualitative data synthesis was also performed. RESULTS: Twenty-one studies were included in the meta-analysis and 33 in the qualitative synthesis. Pooled incidence of second ACL injury was 16.9% (95% confidence interval [CI]: 12.8, 21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (25 days; 95% CI: 9.5, 40.4) than those who did not suffer another injury. There was no difference in time to RTS for professional athletes who suffered a second ACL injury and those who did not. The certainty of evidence was very low. CONCLUSION: There was very low-certainty evidence that patients who suffered a second ACL injury had returned to sport 25 days earlier than patients who did not have another injury. For professional athletes, there was no difference in time to RTS between athletes who suffered a second ACL injury and athletes who did not. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 30 November 2023. doi:10.2519/jospt.2023.11977.

Knee extension deficit during gait and knee extensor weakness persisting after saucerization and repair of discoid lateral meniscus tears

BACKGROUND

Physical function and knee kinematics recovery after discoid lateral meniscus (DLM) tear surgery are essential for a better prognosis. However, these alterations remain unclear. Therefore, this study aimed to investigate changes in physical function and knee kinematics following saucerization and DLM tear repair.

METHODS

We enrolled 16 patients who underwent saucerization and DLM tear repair. Postoperative changes in knee kinematics during gait, and physical function, were evaluated at 3, 6, and 12 months.

RESULTS

The peak flexion angle of the operated limb during weight acceptance was significantly higher than that of the contralateral limb at 3 (operated limb: 34.6 ± 8.9°, contralateral limb: 23.7 ± 8.3°; P < 0.01) and 6 months (operated limb: 32.1 ± 9.7°, contralateral limb: 24.6 ± 8.2°; P = 0.03) postoperatively, but not at 12 months (operated limb: 27.1 ± 7.1°, contralateral limb: 23.1 ± 9.5°; P = 0.22) postoperatively. The knee extensor strength of the operated limb was significantly lower than that of the contralateral limb at 3 (operated limb: 1.00 ± 0.59 Nm/kg, contralateral limb: 1.37 ± 0.59 Nm/kg; P = 0.01), 6 (operated limb: 1.22 ± 0.55 Nm/kg, contralateral limb: 1.48 ± 0.60 Nm/kg; P < 0.01), and 12 months (operated limb: 1.39 ± 0.57 Nm/kg, contralateral limb: 1.55 ± 0.64 Nm/kg; P = 0.04) postoperatively.

CONCLUSION

Knee extension deficits and extensor weakness persisted at 6 months after saucerization and repair of DLM tears. Postoperative rehabilitation should be focused on knee extension function.

A Prospective Randomized Controlled Trial Investigating Quadriceps Versus Hamstring Tendon Autograft in Anterior Cruciate Ligament Reconstruction

BACKGROUND

Numerous graft options are available when undertaking anterior cruciate ligament (ACL) reconstruction (ACLR), although a lack of high-quality evidence exists comparing quadriceps (QT) and hamstring (HT) autografts.

PURPOSE

To investigate patient outcomes in patients undergoing HT versus QT ACLR.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

After recruitment and randomization, 112 patients (HT = 55; QT = 57) underwent ACLR. Patients were assessed pre- and postoperatively (6 weeks and 3, 6, 12, and 24 months), with a range of patient-reported outcome measures (PROMs), graft laxity (KT-1000 arthrometer; primary outcome variable), active knee flexion and extension range of motion (ROM), peak isokinetic knee extensor and flexor strength, and a 6-hop performance battery. Limb symmetry indices (LSIs) were calculated for strength and hop measures. Secondary procedures, ACL retears, and contralateral ACL tears were reported.

RESULTS

All PROMs and knee ROM measures significantly improved (P < .0001), and no other group differences (P > .05) were observed-apart from the Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) score, which was significantly better in the HT group at 3 (P = .008), 6 (P = .010), and 12 (P = .014) months. No significant changes were observed in side-to-side laxity from 6 to 24 months (P = .105), and no group differences were observed (P = .487) at 6 (HT mean, 1.2; QT mean, 1.3), 12 (HT mean, 1.1; QT mean, 1.3), and 24 (HT mean, 1.1; QT mean, 1.2) months. While the HT group demonstrated significantly greater (P < .05) quadriceps strength LSIs at 6 and 12 months, the QT group showed significantly greater (P < .05) hamstring strength LSIs at 6, 12, and 24 months. The HT group showed significantly greater (P < .05) LSIs for the single horizontal (6 months), lateral (6 and 12 months), and medial (6 months) hop tests for distance. Up until 24 months, 1 patient (QT at 22 months) had a retear, with 2 contralateral ACL tears (QT at 19 months; HT at 23 months). Secondary procedures included 5 in the HT group (manipulation under anesthesia, notch debridement, meniscal repair, and knee arthroscopy for scar tissue) and 6 in the QT group (notch debridement, meniscal repair, knee arthroscopy for scar tissue, tibial tubercle transfer, and osteochondral autologous transplantation).

CONCLUSION

Apart from the ACL-RSI, the 2 autograft groups compared well for PROMs, knee ROM, and laxity. However, greater hamstring strength LSIs were observed for the QT cohort, with greater quadriceps strength (and hop test) LSIs in the HT cohort. The longer-term review will continue to evaluate return to sports and later-stage reinjury between the 2 graft constructs.

REGISTRATION

ACTRN12618001520224p (Australian New Zealand Clinical Trials Registry).

Estimation of Vertical Ground Reaction Force during Single-leg Landing Using Two-dimensional Video Images and Pose Estimation Artificial Intelligence

OBJECTIVE

Assessment of the vertical ground reaction force (VGRF) during landing tasks is crucial for physical therapy in sports. The purpose of this study was to determine whether the VGRF during a single-leg landing can be estimated from a two-dimensional (2D) video image and pose estimation artificial intelligence (AI).

METHODS

Eighteen healthy male participants (age: 23.0 ± 1.6 years) performed a single-leg landing task from a 30-cm height. The VGRF was measured using a force plate and estimated using center of mass (COM) position data from a 2D video image with pose estimation AI (2D-AI) and three-dimensional optical motion capture (3D-Mocap). The measured and estimated peak VGRFs were compared using a paired t-test and Pearson's correlation coefficient. The absolute errors of the peak VGRF were also compared between the two estimations.

RESULTS

No significant difference in the peak VGRF was found between the force plate measured VGRF and the 2D-AI or 3D-Mocap estimated VGRF (force plate: 3.37 ± 0.42 body weight [BW], 2D-AI: 3.32 ± 0.42 BW, 3D-Mocap: 3.50 ± 0.42 BW). There was no significant difference in the absolute error of the peak VGRF between the 2D-AI and 3D-Mocap estimations (2D-AI: 0.20 ± 0.16 BW, 3D-Mocap: 0.13 ± 0.09 BW, P = 0.163). The measured peak VGRF was significantly correlated with the estimated peak by 2D-AI (R = 0.835, P <0.001).

CONCLUSION

The results of this study indicate that peak VGRF estimation using 2D video images and pose estimation AI is useful for the clinical assessment of single-leg landing.

Preferences in anterior cruciate ligament reconstruction: A survey among orthopedic surgeons in China

The purpose of this study was to reveal the current trends and preferences of Chinese orthopedic surgeons regarding anterior cruciate ligament (ACL) reconstruction through a nationwide web-based survey conducted in China. The survey questionnaire was distributed via WeChat to the chairmen of provincial orthopedic and sports medicine organizing committees in China, who then shared it in their respective WeChat workgroups. The questionnaire consisted of 52 multiple-choice questions covering 8 sections. Data collection was implemented by Questionnaire Star. A total of 812 valid questionnaires were returned: 94.21% of the respondents preferred single-bundle reconstruction of ACL, while 61.70% preferred autogenous semitendinosus plus gracilis reconstruction; 76.35% of the respondents preferred establishing the femoral tunnel first, while 47.29% preferred establishing the femoral tunnel through a medial auxiliary approach; and 85.10% of the respondents recommended patients to undergo surgery within 3 months after ligament injury. Besides, the vast majority of respondents chose to retain the ligamentous remnant bundle (92.98%) and recommended routine use of knee braces postoperatively (94.09%). It is recommended to perform arthroscopic single-bundle ACL reconstruction with the remnant preserving technique using a hamstring autograft within 3 months of ACL rupture, with support of postoperative functional braces.

Telerehabilitation to Address the Rehabilitation Gap in Anterior Cruciate Ligament Care: Survey of Physical Therapists/Care Providers

Background

While the importance of structured rehabilitation following anterior cruciate ligament reconstruction (ACLR), particularly in the return-to-sport phase, is known, for most patients, supervised physical therapy is often completed before this time point. The recent emergence of telerehabilitation and other digital health interventions has the potential to address this "rehabilitation gap."

Methods

The study was conducted as a cross-section, online survey collecting qualitative and quantitative data from open and closed questions. Inclusion criteria included local qualified physical therapists or other professionals working with ACLR patients.

Results

Eighty-three percent of respondents experienced a "rehabilitation gap" with their ACLR patients. Few reported currently utilizing apps or websites (9.74%). The majority (41/58) reported experience with telerehabilitation, and 84% felt that there was a role for digital rehabilitation strategies to address the "rehabilitation gap." The vast majority (94.74%) of participants felt that standard commercial insurance did not permit sufficient rehabilitation.

Discussion

While the majority of our respondents acknowledged the existence of a "rehabilitation gap," as well as familiarity with and confidence in telerehabilitation, few were using this technique at the time of our survey. This suggests an opportunity for development in this space.

UEFA Women's Elite Club Injury Study: a prospective study on 1527 injuries over four consecutive seasons 2018/2019 to 2021/2022 reveals thigh muscle injuries to be most common and ACL injuries most burdensome

OBJECTIVE

Injuries in women's football (soccer) have scarcely been investigated, and no study has been conducted in the highest competitive level involving club teams from different countries. Our aim was to investigate the time-loss injury epidemiology and characteristics among women's elite football players over four seasons.

METHODS

596 players from 15 elite women's teams in Europe were studied prospectively during the 2018/2019 to 2021/2022 seasons (44 team seasons). Medical staff recorded individual player exposure and time-loss injuries. Injury incidence was calculated as the number of injuries per 1000 playing hours and injury burden as the number of days lost per 1000 hours.

RESULTS

1527 injuries were recorded in 463 players with an injury incidence of 6.7 (95% CI 6.4 to 7.0) injuries per 1000 hours and a nearly fourfold higher incidence during match play compared with training (18.4, 95% CI 16.9 to 19.9 vs 4.8, 95% CI 4.5 to 5.1; rate ratio 3.8, 95% CI 3.5 to 4.2). Thigh muscle injuries (hamstrings 12%, 188/1527, and quadriceps 11%, 171/1527) were the most frequent injury, while anterior cruciate ligament (ACL) injury had the highest burden (38.0 days lost per 1000 hours, IQR 29.2-52.1) with median days lost of 292 (IQR 246-334) days. Concussions constituted 3% (47/1527) of all injuries, with more than half of them (55%, 26/47) due to ball-related impact.

CONCLUSION

An elite women's football team can expect approximately 35 time-loss injuries per season. Thigh muscle injury was the most common injury and ACL injury had the highest injury burden.

Functional Outcomes in Anterior Cruciate Ligament (ACL) Reconstruction: A Nine-Month Follow-up Study Using Lysholm Score in a Rural Tertiary Care Center in India

Introduction The knee joint, an extraordinary feat of biomechanics, is prone to injuries, with the anterior cruciate ligament (ACL) often being a common victim. The intricate coordination of joint movements relies heavily on the ACL's screw-home mechanism, a crucial element for synchronizing knee movement with neighboring joints. Despite its indispensable role, the ACL is susceptible to injury, necessitating surgical intervention. While many patients experience positive outcomes following ACL reconstruction surgeries, a significant proportion face the challenge of procedure failure. The key to success lies in the healing process within the tibial and femoral bone tunnels. The post-ACL reconstruction phase introduces its own set of challenges, particularly in the context of returning to sports (RTS), underscoring the importance of reinstating neuromuscular and motor function. The trajectory of rehabilitation is influenced by factors such as graft healing, patient age, gender, pain levels, and concurrent injuries. Materials and methods This prospective observational study spanned 2.5 years, enrolling 71 patients with diagnosed ACL injuries. Arthroscopic reconstruction utilized hamstring autografts and peroneus longus autografts. A nine-month post-surgery follow-up employed the Lysholm scoring system for comprehensive evaluations. Results Over 2.5 years, 87.3% of male and 12.6% of female participants underwent arthroscopic reconstruction. Lysholm scores revealed 28.1% excellent, 45.0% good, and 26.7% fair outcomes, with no participants in the unsatisfactory range. Lysholm scores demonstrated positive outcomes, indicating the efficacy of arthroscopic reconstruction in enhancing knee function. Findings align with existing literature, emphasizing positive results from ACL reconstruction techniques and specific implants. Comparisons with related studies highlight challenges in standardized return-to-sport guidelines and underscore the need for outcome measure standardization. Conclusion The study contributes nuanced insights into ACL reconstruction outcomes, emphasizing positive functional recovery trends at the nine-month follow-up. Lysholm scores indicate favorable outcomes, supporting the procedure's effectiveness. Consideration of specific implants adds practical value. Despite limitations, this study enriches ACL reconstruction research, promoting advancements in patient care and outcomes. Ongoing research with extended follow-ups and larger cohorts will enhance understanding and refine ACL reconstruction strategies.

Corticomuscular cross-recurrence analysis reveals between-limb differences in motor control among individuals with ACL reconstruction

Surgical reconstruction of the anterior cruciate ligament (ACL) and subsequent physical therapy can help athletes return to competition; however, re-injury rates remain disproportionately high due, in part, to lingering biomechanical and neurological factors that are not fully addressed during rehabilitation. Prior reports indicate that individuals exhibit altered electrical activity in both brain and muscle after ACL reconstruction (ACLR). In this investigation, we aimed to extend existing approaches by introducing a novel non-linear analysis of corticomuscular dynamics, which does not assume oscillatory coupling between brain and muscle: Corticomuscular cross-recurrence analysis (CM-cRQA). Our findings indicate that corticomuscular dynamics vary significantly between involved (injured) and uninvolved legs of participants with ACLR during voluntary isometric contractions between the brain and both the vastus medialis and lateralis. This finding points to a potential lingering neural deficit underlying re-injury for athletes after surgical reconstruction, namely the dynamical structure of neuromuscular (brain to quad muscle) coordination, which is significantly asymmetric, between limbs, in those who have ACLR.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate

PURPOSE

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports.

METHODS

This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively.

RESULTS

We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001).

CONCLUSIONS

At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.