Which criteria are used to clear patients to return to sport after primary ACL reconstruction? A scoping review

Examination of the Feasibility of a 2-Dimensional Portable Assessment of Knee Joint Stability: A Pilot Study

Rupture of the anterior cruciate ligament (ACL) remains extremely common, with over 250,000 injuries annually. Currently, clinical tests have poor utility to accurately screen for ACL injury risk in athletes. In this study, the position of a knee marker was tracked in 2-dimensional planes to predict biomechanical variables associated with ACL injury risk. Three-dimensional kinematics and ground reaction forces were collected during bilateral, single-leg stop-jump tasks for 44 healthy male military personnel. Knee marker position data were extracted to construct 2-dimensional 95% prediction ellipses in each anatomical plane. Knee marker variables included: ellipse areas, major/minor axes lengths, orientation of ellipse axes, absolute ranges of knee position, and medial knee collapse. These variables were then used as predictor variables in stepwise multiple linear regression analyses for 7 biomechanical variables associated with ACL injury risk. Knee flexion excursion, normalized peak vertical ground reaction forces, and knee flexion angle at initial contact were the response variables that generated the highest adjusted R2 values: .71, .37, and .31, respectively. The results of this study provide initial support for the hypothesis that tracking a single marker during 2-dimensional analysis can accurately reflect the information gathered from 3-dimensional motion analysis during a task assessing knee joint stability.

Patient function in serial assessments throughout the post-ACL reconstruction progression

OBJECTIVE

To assess the changes in patient strength and function from 4- to 6-month assessments following ACLR, determine relationships between changes in strength to changes in subjective function, and identify factors that predict patients that fail to increase in strength.

DESIGN

Prospective, Cohort Study.

SETTING

Controlled Laboratory.

PARTICIPANTS

Forty-seven patients(27 female, 24.3 ± 11.1 years) completed a battery of performance assessments at approximately 4- and 6-months following primary ACLR (4.03 ±0 .49 and 6.46 ±0 .68 months).

MAIN OUTCOME MEASURES

Subjective scores and isokinetic knee flexor and extensor strength were compared across visits. Patients were categorized per their ability to increase in strength beyond a previously defined threshold(0.22 Nm/kg). Binary logistic regression models were used to determine predictors of patients that failed to meet strength changes.

RESULTS

Patients demonstrated improvements in patient-reported outcomes and strength measures between visits(P's < 0.05). Higher age (B = -0.073, P = .039), lower pre-injury activity levels (B = 0.61, P = .022), and higher limb symmetry indexes (B = -0.044, P = .05) at 4-months were predictors of patients that did not achieve improvements in quadriceps strength between assessments.

CONCLUSIONS

From 4- to 6-months post-ACLR, increases in subjective function, strength and symmetry were observed. High quadriceps symmetry at interim assessments without consideration of the magnitude of strength values could overestimate recovery of quadriceps function.

The 6-m Timed Hop Is Not a Suitable Clinical Assessment Tool for Use Following Anterior Cruciate Ligament Reconstruction

CONTEXT

Single-leg hop tests are used to assess functional performance following anterior cruciate ligament (ACL) reconstruction. Recording 6-m timed hop scores using a stopwatch increases the potential for misclassification of patient status due to the number of error sources present.

OBJECTIVE

To examine the consistency of pass/fail (>90% limb symmetry index [LSI]) decisions in athletes tested at discharge following ACL reconstruction during the 6-m timed hop and the agreement between different human raters using a stopwatch and an electronic timing system.

SETTING

Clinic, rehabilitation.

PARTICIPANTS

A total of 20 professional soccer players (age 24.6 [4.2] y; height 175.3 [10.2] cm; mass 73.6 [14.5] kg; 36 [10.5] wk following ACL reconstruction) volunteered to take part in this study.

MAIN OUTCOME MEASURES

Two individual raters recorded each trial of the 6-m timed hop test on each limb with a stopwatch and an electronic timing system acted as the criterion measure. LSI scores were also computed with a pass score >90% LSI.

RESULTS

No significant differences were observed between limbs for any scoring method (P > .05). Mean differences indicated the electronic timing system was slower than both human raters (P < .05). Five participants failed the test (<90% LSI) but on each occasion this was only recorded by one method of rating. Kappa statistics showed no agreement in LSI scores across all 3 methods of scoring (κ = -.13) and no agreement when comparing the light gates to individual raters and rater 1 versus 2 (κ < 0). 95% limits of agreement in LSI scores recorded values of approximately ±20%.

CONCLUSIONS

The 6-m timed hop test recorded using a stopwatch is not a valid measure to make clinical decisions following ACL reconstruction. Systematic bias between methods also suggests that a stopwatch and electronic timing system cannot be used interchangeably.

Relationship between pre- and post-operative isokinetic strength after ACL reconstruction using hamstring autograft

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are of major concern in sports. As mostly young and active individuals are affected there is an emphasis on the rapid and safe return to sports (RTS). Strengthening the ventral and dorsal thigh muscles is a prerequisite for a successful RTS after ACL reconstruction (ACLR), as persistent muscle weakness may increase the incidence for secondary injuries and impair performance. Aiming to increase evidence on the importance of preoperative muscle strength and the coaching of patients, the purpose of this study is to compare thigh muscle strength pre- and post-operatively after ACLR.

METHODS

We performed a retrospective analysis of 80 patients with primary, isolated ACLR using a four-stranded hamstring autograft. We performed bilateral isokinetic concentric strength measurement (60°/s) before and six months after ACLR. Primary outcomes were the maximal knee extension and flexion torque, hamstrings-to-quadriceps ratio (H/Q ratio) and the corresponding limb symmetry indices (LSI). Pearson correlations were calculated for pre- and post-surgical values.

RESULTS

The operated as well as the unaffected leg increased maximal knee extension (+ 18% ± 7% p < 0.05; + 11% ± 5% p < 0.05) and flexion torque (+ 9% ± 5% p < 0.05, + 10% ± 6% p < 0.05) throughout the 6 months of rehabilitation. The H/Q ratio remained unaffected (- 2% ± 3% p = 0.93; - 4% ± 4% p = 0.27). LSI of knee extension strength increased significantly (6% ± 3% p < 0.05), while flexion strength remained unaffected (+ 2% ± 4% p = 0.27). Positive correlations underline the interrelationship between the strength pre- and post-surgery for the knee extension (r = 0.788 p < 0.05) and knee flexion strength (r = 0.637 p < 0.05) after ACLR.

CONCLUSIONS

Preoperative leg extension and flexion strength normalized to body mass are strongly correlated to postoperative strength performance after ACLR. Therefore, pre-operative quadriceps and hamstring muscle strength deficits may have a significant negative impact on functional performance following ACLR. This emphasizes the need for intensive preoperative screening and subsequent treatment to achieve the best possible preoperative leg strength before ACLR.

TRIAL REGISTRATION

DRKS00020210 .

Adding a modified Lemaire procedure to ACLR in knees with severe rotational knee instability does not compromise isokinetic muscle recovery at the time of return-to-play

Purpose

To determine whether isokinetic muscle recovery following ACLR using a hamstring tendon (HT) would be equivalent (non-inferior) in knees that had high-grade pivot-shift and adjuvant modified Lemaire procedure versus knees that had minimal pivot-shift and no adjuvant modified Lemaire procedure.

Methods

We evaluated 96 consecutive patients that underwent primary ACLR. Nine were excluded because of contralateral knee injury, and of the remaining 87, ACLR was performed stand-alone in 52 (Reference group), and with a Lemaire procedure in 35 (Lemaire group) who had high-grade pivot-shift, age < 18, or genu recurvatum > 20°. At 6 months, isokinetic tests were performed at 240°/s and 90°/s to calculate strength deficits of hamstrings (H) and quadriceps (Q). At 8 months, patients were evaluated using IKDC, Lysholm, and Tegner scores.

Results

Compared to the Reference group, the Lemaire group were younger (23.0 ± 2.5 vs 34.2 ± 10.5, p = 0.021) with a greater proportion of males (80% vs 56%, p < 0.001). The Lemaire group had no complications, but the Reference group had one graft failure and one cyclops syndrome. Strength deficits at 240°/s and at 90°/s were similar in both groups, but mixed H/Q ratios were lower for the Lemaire group (1.02 ± 0.19 vs 1.14 ± 0.24, p = 0.011). IKDC and Lysholm scores were similar in both groups, but Tegner scores were higher in the Lemaire group (median, 6.5 vs 6.0, p = 0.024).

Conclusions

ACLR with a modified Lemaire procedure for knees with rotational instability grants equivalent isokinetic muscle recovery as stand-alone ACLR in knees with no rotational instability. For ACL-deficient knees with high-grade pivot-shift, a Lemaire procedure restores rotational stability without compromising isokinetic muscle recovery.

Study design

Level III, comparative study.

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

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

THE SUCCESS OF RETURN TO SPORT AFTER SUPERIOR LABRUM ANTERIOR TO POSTERIOR (SLAP) TEARS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Reviews on superior labral anterior to posterior (SLAP) injuries have been reported in the literature. However, current reviews have not focused on the success of athletes return to their previous level of sport or athletic performance.

Hypothesis/Purpose

Systematically review return to sport (RTS) and return to sport at previous level (RTSP) proportions after SLAP injury while reporting any additional performance metrics and outcome measures.

Study Design

Systematic Review & Meta-Analysis.

Methods

A computer assisted literature search of MEDLINE, CINAHL, Embase and SportDiscus databases utilizing keywords related to RTS post-surgery for SLAP tear was implemented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized for study methodology. Quality assessment utilized the MINORS scale.

Results

Twenty-two studies (617 athletes) qualified for analysis. Based on limited evidence from level 3b to 4 studies, athletes RTS post intervention for SLAP injury occurred at a rate of 93% (95% CI:87 to 98%) and overall RTSP rate was 72% (95% CI:60 to 83%). The mean time to RTS post intervention was reported in 59% of studies at 6.9 ± 2.9 months. Patient reported outcome measures (PROM's) were reported in 86% of studies. There was limited reporting of performance statistics, rehabilitation guidelines, return to sport criteria, and information regarding SLAP diagnosis in the available studies. None of the included studies reported post-surgical athletic performance or career longevity.

Conclusions

Limited evidence suggests that less than three in four athletes return to their previous level of sport participation after SLAP injury intervention. Treatment success for an athlete with SLAP injury remains relatively unknown as only 59% of included studies clearly delineate RTS from RTSP and neither athletic performance nor career longevity were reported in any included studies. Future studies of higher quality are required for this determination.

Level of Evidence

Level 1a.

Strength and Power Training in Rehabilitation: Underpinning Principles and Practical Strategies to Return Athletes to High Performance

Injuries have a detrimental impact on team and individual athletic performance. Deficits in maximal strength, rate of force development (RFD), and reactive strength are commonly reported following several musculoskeletal injuries. This article first examines the available literature to identify common deficits in fundamental physical qualities following injury, specifically strength, rate of force development and reactive strength. Secondly, evidence-based strategies to target a resolution of these residual deficits will be discussed to reduce the risk of future injury. Examples to enhance practical application and training programmes have also been provided to show how these can be addressed.

Preoperative quadriceps strength as a predictor of return to sports after anterior cruciate ligament reconstruction in competitive athletes

OBJECTIVES

To determine whether preoperative quadriceps strength predicts the likelihood of return to sports (RTS) following anterior cruciate ligament reconstruction (ACLR) in competitive athletes.

DESIGN

Case-control study.

SETTING

Single-center.

PARTICIPANTS

A total of 221 competitive athletes who underwent primary ACLR were followed and divided into RTS (n = 177) and non-RTS (n = 44) groups based on self-reported sports activities at one year postoperatively.

MAIN OUTCOME MEASURES

Isokinetic quadriceps strength tests were performed preoperatively and at six months and one year postoperatively, and the quadriceps index (QI) was calculated. Functional performance was evaluated by the single-leg hop (SLH) test at six months postoperatively.

RESULTS

Preoperative QI significantly predicted the likelihood of RTS (odds ratio, 1.68 per 10-unit increase; P < 0.001), with a preoperative QI cut-off of 66% (AUC: 0.74; sensitivity: 68.9%; specificity: 77.3%). Subjects with a preoperative QI < 66% had a significantly lower postoperative QI, SLH, and rates of RTS compared to those with a higher preoperative QI (P < 0.01).

CONCLUSIONS

Preoperative quadriceps strength could predict the likelihood of RTS following ACLR, and a preoperative QI < 66% was associated with a greater risk of unsuccessful RTS at one year postoperatively. Preoperative QI should be evaluated as a predictor of RTS.

Hop tests and psychological PROs provide a demanding and clinician-friendly RTS assessment of patients after ACL reconstruction, a registry study

Background

There is growing interest in assessing psychological well-being in patients after anterior cruciate ligament (ACL) reconstruction. It is unknown whether an assessment of psychological outcome in addition to tests of muscle function can facilitate decisions on return to sport (RTS). Therefore, the aim of this study was to evaluate passing rates in different physical RTS test batteries, with and without the inclusion of psychological outcome measures 1 year after ACL reconstruction.

Method

In this cross-sectional cohort study a total of 320 patients (51% men) aged 18–65 years were included 1 year after ACL reconstruction. Passing rates on different muscle function (MF) test batteries (with results presented as Limb Symmetry Index (LSI)), consisting of knee extension and flexion strength tests, 3 hop tests, and 2 psychological patient-reported outcomes (PROs); Quality of Life subscale from the Knee injury and Osteoarthritis Outcome Score (KOOS QoL) and ACL Return to Sport after Injury (ACL-RSI), were evaluated 1 year after ACL reconstruction. Muscle function test batteries comprised: 2 MF tests (vertical hop and hop for distance; pass = 90% LSI); 2 MF tests and 2 PRO (pass = 90% LSI, 62.5 points on KOOS QoL and 76.6 points on ACL-RSI), 5 MF tests (2 strength and 3 hop tests, pass = 90% LSI), and 5 MF tests and 2 PRO (pass = 90% LSI, 62.5 points on KOOS QoL and 76.6 points on ACL-RSI).

Results

Passing rates in the different test batteries were 47% for 2 MF tests, 19% for 2 MF tests and 2 PROs, 29% for 5 MF tests and 13% for 5 MF tests and 2 PROs. The use of psychological PROs together with tests of muscle function gave the lowest passing rate (13%). There was a very strong correlation between passing 2 hop tests and 2 PROs and passing 5 MF tests (rφ = 0.41) as well as passing 5 MF tests and 2 PROs (rφ = 0.79).

Conclusion

The use of hop tests together with psychological PROs provides a clinician-friendly RTS test battery for assessment 1 year after ACL reconstruction as the passing rate was 19% when using 2 hop-tests combined with 2 PROs, compared with 29% when using 5 tests of MF requiring advanced testing equipment.

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

CONTEXT

Anterior cruciate ligament (ACL) reconstruction (ACLR) is frequently performed in patients younger than 20 years whose goal is to return to sport (RTS). Varying reinjury rates have been reported, and the factors responsible are unclear. Studies differ with regard to age, graft type, surgical techniques, postoperative rehabilitation, RTS guidelines, and methods used to determine ACL failures.

OBJECTIVE

To determine RTS rates; the effect of participation in high-risk sports, sex, and graft type on ACL reinjury rates; and whether objective test criteria before RTS correlate with lower reinjury rates.

DATA SOURCES

A systematic review of the literature from inception to May 31, 2019, was conducted using the PubMed and Cochrane databases.

STUDY SELECTION

Studies on transphyseal ACLR in athletes <20 years old with a minimum mean follow-up of 2 years that reported reinjury rates, the number that RTS, and detailed the type of sport were included.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 1239 patients in 8 studies were included; 87% returned to sport and 80% resumed high-risk activities. Of the patients, 18% reinjured the ACL graft and/or the contralateral ACL. Nine percent of patellar tendon autografts and 15% of hamstring autografts failed (odds ratio [OR], 0.52; P = 0.002). Of reinjuries, 90% occurred during high-risk sports. Male patients had a significantly higher rate of ACL graft failure than female patients (OR, 1.64; P = 0.01). There was no sex-based effect on contralateral ACL injuries. Only 1 study cited objective criteria for RTS.

CONCLUSION

A high percentage of athletes returned to sport, but 1 in 5 suffered reinjuries to either knee. Male patients were more likely to reinjure the ACL graft. Objective criteria for RTS were rarely mentioned or not detailed. The need for testing of knee stability, strength, neuromuscular control, agility, and psychological measures before RTS remains paramount in young athletes.

Lower Limb Kinetic Asymmetries in Professional Soccer Players With and Without Anterior Cruciate Ligament Reconstruction: Nine Months Is Not Enough Time to Restore "Functional" Symmetry or Return to Performance

BACKGROUND

Residual between-limb deficits are a possible contributing factor to poor outcomes in athletic populations after anterior cruciate ligament reconstruction (ACLR). Comprehensive appraisals of movement strategies utilized by athletes at key clinical milestones during rehabilitation are warranted.

PURPOSE

To examine kinetic parameters recorded during a countermovement jump with a force platform in healthy professional soccer players and to compare their performance with those who had undergone ACLR at different stages of their rehabilitation.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 370 male professional soccer players attended a physical screening assessment where they performed at counter jump movement protocol on dual force plates and were divided into 4 groups: group 1 (<6 months post-ACLR), group 2 (6-9 months post-ACLR), group 3 (>9 months post-ACLR), and group 4 (healthy matched controls).

RESULTS

Players in the later phases of rehabilitation increased their jump performance; however, values were significantly lower than those of healthy matched controls (P > .05). Significant between-limb differences were present for both eccentric- and concentric-phase variables (P < .05), with effect sizes ranging from moderate to very large (d = 0.42-1.35). Asymmetries were lower in players who were further away from surgery; however, between-limb differences remained significantly greater in players >9 months after ACLR versus matched controls-specifically, for concentric impulse, concentric peak force, eccentric deceleration impulse, and eccentric deceleration rate of force development asymmetry (P < .05). Logistic regression identified concentric impulse asymmetry as being most strongly associated with a history of ACLR when group prediction analysis was performed (ACLR group 1, 2, or 3 vs matched controls), with odds ratios ranging from 1.50 to 1.91.

CONCLUSION

Between-limb deficits in key eccentric and concentric loading parameters remain >9 months after ACLR, indicating a compensatory offloading strategy to protect the involved limb during an athletic performance task. Concentric impulse asymmetry could be considered an important variable to monitor during rehabilitation.

Poor functional performance 1 year after ACL reconstruction increases the risk of early osteoarthritis progression

Background

Not meeting functional performance criteria increases reinjury risk after ACL reconstruction (ACLR), but the implications for osteoarthritis are not well known.

Objective

To determine if poor functional performance post-ACLR is associated with risk of worsening early osteoarthritis features, knee symptoms, function and quality of life (QoL).

Methods

Seventy-eight participants (48 men) aged 28±15 years completed a functional performance test battery (three hop tests, one-leg-rise) 1 year post-ACLR. Poor functional performance was defined as <90% limb symmetry index (LSI) on each test. At 1 and 5 years, MRI, Knee injury Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) subjective form were completed. Primary outcomes were: (i) worsening patellofemoral and tibiofemoral MRI-osteoarthritis features (cartilage, bone marrow lesions (BMLs) and meniscus) and (ii) change in KOOS and IKDC scores, between 1 and 5 years.

Results

Only 14 (18%) passed (≥90% LSI on all tests) the functional test battery. Poor functional performance on the battery (all four tests <90% LSI) 1 year post-ACLR was associated with 3.66 times (95% CI 1.12 to 12.01) greater risk of worsening patellofemoral BMLs. A triple-crossover hop <90% LSI was associated with 2.09 (95% CI 1.15 to 3.81) times greater risk of worsening patellofemoral cartilage. There was generally no association between functional performance and tibiofemoral MRI-osteoarthritis features, or KOOS/IKDC scores.

Conclusion

Only one in five participants met common functional performance criteria (≥90% LSI all four tests) 1 year post-ACLR. Poor function on all four tests was associated with a 3.66 times increased risk of worsening patellofemoral BMLs, and generally not associated with decline in self-reported outcomes.

Within-day test-retest reliability of an accelerometer-based method for registration of step time symmetry during stair descent after ACL reconstruction and in healthy subjects

Background: Symmetry during stair descent can potentially be used as an early functional measure after anterior cruciate ligament reconstruction (ACLR). We have developed a novel application of a single accelerometer-based inertial motion unit (IMU) to identify foot strikes and calculate step times in an ordinary stairway.Purpose: To examine within-day test-retest reliability and measurement error of step time and step time symmetry measured with a body-fixed IMU during stair descent in subjects early after ACLR and in healthy subjects.Methods: Subjects after ACLR were tested twice 6 weeks (N = 15) and twice 3 months (N = 26) postoperatively. Eighteen healthy subjects were tested twice on one occasion. Subjects descended a flight of stairs at preferred speed. Trunk accelerometry data were collected with an inertial motion unit (IMU). Mean step times (MSTs) and limb symmetry index (LSI) of MSTs were calculated. Clinical trials registration number: NCT01279759.Results: Intraclass Correlation Coefficient (ICC (1,1)) for within test-retest reliability varied from 0.87 to 0.96 for MSTs and from 0.58 to 0.87 for LSIs. The 95% confidence interval (CI) for a true value varied from ± 0.02 seconds (s) to ± 0.05 s for MSTs and from ± 4.6 percentage points (pp) to ± 6.6 pp for LSIs.Conclusion: Mean step times measured with a body-fixed IMU during stair descent and limb symmetry indexes calculated from these mean step times are precise and reliable during early post-operative rehabilitation after ACLR and in healthy subjects.

Quadriceps and Hamstring Strength Symmetry After Anterior Cruciate Ligament Reconstruction: A Prospective Study

OBJECTIVES

To evaluate change in involved and uninvolved quadriceps and hamstring strength and limb symmetry indices (LSI) in regular intervals over the first 6 months following anterior cruciate ligament reconstruction (ACLR).

DESIGN

Prospective cohort study.

PARTICIPANTS

Thirty-eight male participants (mean age: 24.2 [6.4] y, mean body mass index: 23.6 [4.2] kg/m2), who underwent ACLR were included.

MAIN OUTCOME MEASURES

Isometric strength testing of the quadriceps and hamstring muscles was performed at 1, 2, 3, and 6 months after ACLR. Quadriceps and hamstring peak torques for each limb and LSI were calculated. Repeated-measures analysis of covariance and paired t tests were used to evaluate changes in strength over time and between limbs, respectively.

RESULTS

Quadriceps and hamstring peak torques of the involved limb consistently increased between each time point from 1 to 6 months (P < .001 and P = .01, respectively), whereas the uninvolved limb values did not change after ACLR (P > .05). In addition, uninvolved limb peak torque values were higher than involved limb values at each time point after ACLR for both the quadriceps and hamstrings (all P < .01). At 6 months after ACLR, 28.9% of participants demonstrated LSI greater than 90% for quadriceps strength, 36.8% demonstrated LSI greater than 90% for hamstring strength, and 15.8% of participants demonstrated greater than 90% LSI for both quadriceps and hamstring strength.

CONCLUSIONS

Participants demonstrated a consistent increase in quadriceps and hamstring strength of the involved limb, with no notable change in uninvolved limb strength over the 6 months after ACLR. However, at 6 months after ACLR, only approximately 16% of participants demonstrated both quadriceps and hamstring strength LSI greater than 90%, the typically recommended cutoff value for return to sport.

Change of Direction Assessment Following Anterior Cruciate Ligament Reconstruction: A Review of Current Practice and Considerations to Enhance Practical Application

Change of direction (CoD) has been indicated as a key mechanism in the occurrence of anterior cruciate ligament (ACL) injury during invasion sports. Despite these associations, assessments of knee function in athletic populations at the time of return to sport following ACL reconstruction (ACLr) have often focused on strength and single-leg hop tests, with a paucity of evidence to describe the CoD characteristics. Therefore, the aim of this narrative review was to describe the movement strategies exhibited following ACLr during CoD tasks and to critically analyze the range of tests that have been used. Specifically, we examined their ability to identify between-limb deficits and individuals who display a heightened risk of secondary injury and/or reductions in their level of pre-injury performance. MEDLINE, PubMed and SPORT Discuss databases were used and 13 articles were identified that met the inclusion criteria. Examination of the available literature indicates that current field-based practices are not representative of relevant sport demands and are unable to effectively assess knee function following ACLr. Laboratory-based studies have identified residual deficits and altered movement strategies at the time of return to sport, and this in part may be related to risk of re-injury. However, these assessments exhibit inherent limitations and are not practically viable for monitoring progress during rehabilitation. Consequently, alternative solutions that are more-aligned with the multitude of factors occurring during CoD maneuvers in chaotic sports environments are warranted to allow practitioners to 'bridge the gap' between the laboratory and the sports field/court. This approach may facilitate a more informed decision-making process with the end goal being, a heightened 'return to performance' and a lower risk of re-injury.

The effect of meniscal repair on strength deficits 6 months after ACL reconstruction

INTRODUCTION

Ruptures of the anterior cruciate ligament (ACL) can be accompanied by meniscal lesions. Generally, the rehabilitation protocols are altered by meniscal repair. Therefore, the aim of this study was to investigate the effect of meniscal repair on the early recovery of thigh muscle strength in ACL reconstruction (ACLR).

MATERIALS AND METHODS

We performed a matched cohort analysis of n = 122 isolated ACLR (CON) compared to n = 61 ACLR with meniscal repair (ACLR + MR). The subgroups of meniscal repair consisted of 30 patients who had undergone medial meniscus repairs (MM), 19 lateral meniscus repairs (LM) and 12 repairs of medial and lateral meniscus (BM). Isokinetic strength measurement was performed pre-operatively and 6 months post-surgery to perform a cross-sectional and a longitudinal analysis. All injuries were unilateral, and the outcome measures were compared to the non-affected contralateral leg.

RESULTS

Six months postoperatively overall there is no significant difference between the groups (extension strength MR 82% vs. CON 85% and flexion strength 86% vs. 88%, resp.). Subgroup analysis showed that medial repairs exhibit a comparable leg symmetry while lateral repairs performed worse with leg symmetry being 76% in extension and 81% in flexion strength. Patients undergoing BM repair performed in between lateral and medial repairs (82% extension, 86% flexion).

CONCLUSION

Generally, meniscal repair in conjunction with ACLR does not significantly alter the recovery of limb symmetry in strength at 6 months postoperatively. Interestingly, medial repairs seem to perform superior to lateral meniscal repair and repair of both menisci. Since the recovery of symmetric strength is a major factor in rehabilitation testing, these results will help to advise surgeons on appropriate rehabilitation protocols and setting realistic goals for the injured athlete.

LEVEL OF EVIDENCE

III, retrospective cohort study.

How Much Time Is Needed Between Serial "Return to Play" Assessments to Achieve Clinically Important Strength Gains in Patients Recovering From Anterior Cruciate Ligament Reconstruction?

BACKGROUND

Pass rates for return-to-play evaluations are alarmingly low for patients after anterior cruciate ligament reconstruction (ACLR). Since timing of return to play is a complicated decision, it is important that patients be given optimal time to realize meaningful improvements in strength that warrant additional testing.

PURPOSE

To (1) compare outcomes among patients assessed at different time points after ACLR, (2) determine strength gains indicative of improvements in subjective function, and (3) determine the amount of time necessary to achieve meaningful strength gains.

STUDY DESIGN

Cross-sectional/case-control study; Level of evidence, 3.

METHODS

A total of 293 patients participated in the study after ACLR (mean ± SD, 23.2 ± 10.1 years old; n = 142 female participants; 6.4 ± 0.9 months after ACLR). Participants were stratified on the month of their evaluation after ACLR: 5 to 6 months (n = 122), 6 to 7 months (n = 102), 7 to 8 months (n = 43), and 8 to 9 months (n = 26). The International Knee Documentation Committee (IKDC) subjective form and knee extensor and flexor torque and symmetry, as assessed through an isokinetic dynamometer, were compared among groups. Forty patients (20 female participants, 20.4 ± 7.1 years old) were referred for subsequent testing (2.14 ± 0.78 months after initial visit). Subjective improvement between visits was defined as a ≥9-point change of the IKDC score. Thresholds of knee extensor torque and symmetry indicative of subjective improvement and the time between assessments needed to achieve these strength improvements were determined.

RESULTS

Patients between 5 and 6 months (IKDC, 79.7; interquartile range [IQR], 70.1-88.5) had lower subjective function compared to patients between 6 and 7 months (IKDC, 83.9; IQR, 74.5-92.0; P = .019) and 8 and 9 months after ACLR (IKDC, 89.1; IQR 75.8-92.3; P = .026). Patients between 5 and 6 months (1.41 N·m/kg; IQR, 1.16-1.73 N·m/kg]) had lower knee extensor torque compared to patients 6 and 7 months (1.59 N·m/kg; IQR, 1.23-1.95 N·m/kg; P = .013) and 7 and 8 months after ACLR (1.62 N·m/kg; IQR, 1.30-1.86 N·m/kg; P = .046). Patients between 5 and 6 months (66.4%; IQR, 54.2-78.6) had lower symmetry compared to patients between 6 and 7 months (71.8%; IQR,61.1-82.9; P = .019) and 8 and 9 months afterACLR (75.2%; IQR, 66.6-87.7; P = .014). Of the 40 patients that completed follow-up assessments, an increase in knee extensor torque of 0.22 N·m/kg and symmetry of 5.75% discriminated patients that achieved subjective improvement. A period of 1.97 months between assessments discriminated those that achieved the established symmetry threshold.

CONCLUSION

Patients demonstrate increasing subjective and quadriceps function when tested at later time points from surgery; however, the observed values are low, suggesting that at 9 months patients are demonstrating deficits that may be improving. Approximately 2 months is needed to observe clinically meaningful improvements.

Eighty-two per cent of male professional football (soccer) players return to play at the previous level two seasons after Achilles tendon rupture treated with surgical repair

OBJECTIVE

To evaluate the time to return to playing following acute Achilles tendon rupture (ATR) and surgical repair in professional male football (soccer) players.

METHODS

Professional male football (soccer) players who sustained an ATR and underwent surgical repair were identified through internet-based injury reports from January 2008 to August 2018. Only League 1 and 2 players with injuries who had at least 1 year of follow-up from the search date were included. Injury history and time to return to play were retrieved from the public platform transfermarkt.com. For athletes who competed for at least two seasons after returning to play, re-ruptures and number of matches played were reported.

RESULTS

118 athletes (mean age 27.2±7.2 years) were included. 113 (96%) returned to unrestricted practice after a mean of 199±53 days, with faster recovery in players involved in national teams. Return to competition was after a mean of 274±114 days. In the 76 athletes with at least two seasons of follow-up, 14 (18%) did not compete at the pre-injury level during the two seasons following the index injury. Six players (8%) sustained a re-rupture within the first two seasons after return to play; four re-ruptures were in footballers who returned to play <180 days after injury. Age >30 years and re-ruptures had higher odds ratios of not returning to the same level of play.

CONCLUSIONS

96% of professional male football players who underwent surgery to repair an ATR returned to unrestricted practice and then competition after an average time of 7 and 9 months, respectively. However, 18% did not return to the same level of play within the two seasons following their return, with a higher risk in those experiencing a re-rupture.

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

OBJECTIVES

To summarise recommendations and appraise the quality of international clinical practice guidelines (CPGs) for rehabilitation after ACL reconstruction.

DESIGN

Systematic review of CPGs (PROSPERO number: CRD42017020407).

DATA SOURCES

Pubmed, EMBASE, Cochrane, SPORTDiscus, PEDro and grey literature databases were searched up to 30 September 2018.

ELIGIBILITY CRITERIA

English-language CPGs on rehabilitation following ACL reconstruction that used systematic search of evidence to formulate recommendations.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report the systematic review. Two appraisers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument to report comprehensiveness, consistency and quality of CPGs. We summarised recommendations for rehabilitation after ACL reconstruction.

RESULTS

Six CPGs with an overall median AGREE II total score of 130 points (out of 168) and median overall quality of 63% were included. One CPG had an overall score below the 50% (poor quality score) and two CPGs scored above 80% (higher quality score). The lowest domain score was 'applicability' (can clinicians implement this in practice?) (29%) and the highest 'scope and purpose' (78%) and 'clarity of presentation' (75%). CPGs recommended immediate knee mobilisation and strength/neuromuscular training. Early full weight-bearing exercises, early open and closed kinetic-chain exercises, cryotherapy and neuromuscular electrostimulation may be used according individual circumstances. The CPGs recommend against continuous passive motion and functional bracing.

CONCLUSION

The quality of the CPGs in ACL postoperative rehabilitation was good, but all CPGs showed poor applicability. Immediate knee mobilisation and strength/neuromuscular training should be used. Continuous passive motion and functional bracing should be eschewed.