Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults

Review article: Best practice management of common knee injuries in the emergency department (part 3 of the musculoskeletal injuries rapid review series)

Knee injuries are a common presentation to the ED and are often difficult to assess and definitively diagnose due to the patient's acute pain, effusion and guarding. The quality of ED care provided to patients with fractures or soft tissue injuries of the knee is critical to ensure the best possible outcomes for the patient. This rapid review investigated best practice for the assessment and management of common knee injuries in the ED. Databases were searched in 2017, including PubMed, CINAHL, EMBASE, TRIP and the grey literature, including relevant organisational websites. Primary studies, systematic reviews and guidelines were considered for inclusion. English-language articles published in the past 12 years that addressed the acute assessment, management, follow-up plan or prognosis were included. Data extraction of included articles was conducted, followed by quality appraisal to rate the level of evidence where possible. The search revealed 2250 articles, of which 54 were included in the review (n = 8 primary articles, n = 28 systematic reviews, n = 18 guidelines). This rapid review provides clinicians managing fractures and soft tissue injuries of the knee in the ED, a summary of the best available evidence to enhance the quality of care for optimal patient outcomes. There is consistent evidence to support undertaking a thorough history and physical examination, including the application of special tests and clinical decision rules for imaging. In the undifferentiated knee injury, expedited follow up and further imaging is recommended to improve patient outcomes and cost-effectiveness.

Guideline on anterior cruciate ligament injury

The Dutch Orthopaedic Association has a long tradition of development of practical clinical guidelines. Here we present the recommendations from the multidisciplinary clinical guideline working group for anterior cruciate ligament injury. The following 8 clinical questions were formulated by a steering group of the Dutch Orthopaedic Association. What is the role of physical examination and additional diagnostic tools? Which patient-related outcome measures should be used? What are the relevant parameters that influence the indication for an ACL reconstruction? Which findings or complaints are predictive of a bad result of an ACL injury treatment? What is the optimal timing for surgery for an ACL injury? What is the outcome of different conservative treatment modalities? Which kind of graft gives the best result in an ACL reconstruction? What is the optimal postoperative treatment concerning rehabilitation, resumption of sports, and physiotherapy? These 8 questions were answered and recommendations were made, using the "Appraisal of Guidelines for Research and Evaluation" instrument. This instrument seeks to improve the quality and effectiveness of clinical practical guidelines by establishing a shared framework to develop, report, and assess. The steering group has also developed 7 internal indicators to aid in measuring and enhancing the quality of the treatment of patients with an ACL injury, for use in a hospital or practice.

Functional tests should be accentuated more in the decision for ACL reconstruction

A high pre-injury activity level, the desire of the patient to continue pivoting sports and fear of future give-way episodes are considered the most significant factors affecting the decision to perform anterior cruciate ligament reconstruction. However, since the functional status of the knee at the time of surgery affects the final outcome, assessments of knee function should be considered in the decision making for surgery. Individuals with anterior cruciate ligament injury can be classified as potential copers or non-copers from an existing screening examination. The purpose of this study was to investigate whether the functional tests incorporated in the original screening examination could contribute to explain those who later go through anterior cruciate ligament reconstruction and to examine whether changes to the content or the time of conducting the screening examination (before or after ten sessions of exercise therapy) could improve its explanatory value. One-hundred and forty-five individuals were included and prospectively followed for 15 months, after where 51% had gone through anterior cruciate ligament reconstruction and 49% were managed non-operatively. The only significant baseline differences between those who later went through anterior cruciate ligament reconstruction and those who were non-operatively treated were that those who had surgery were younger and had a higher activity level (P < 0.05). Regression analyses revealed that the explanatory value for those who later went through anterior cruciate ligament reconstruction significantly improved when the original screening examination was considered compared to only age, activity level and give-way episodes. Changes to the content further improved the explanatory value, with quadriceps muscle strength as the single variable with the highest impact. Finally, conducting the screening examination after ten sessions of progressive exercise therapy gave the overall highest explanatory values, suggesting that the screening examination should be conducted subsequent to a short period of rehabilitation to inform decision making for anterior cruciate ligament reconstruction.

A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury

STUDY DESIGN

Prospective cohort study without a control group.

OBJECTIVES

Firstly, to present our 5-week progressive exercise therapy program in the early stage after anterior cruciate ligament (ACL) injury. Secondly, to evaluate changes in knee function after completion of the program for patients with ACL injury in general and also when classified as potential copers or noncopers, and, finally, to examine potential adverse events.

BACKGROUND

Few studies concerning early-stage ACL rehabilitation protocols exist. Consequently, little is known about the tolerance for, and outcomes from, short-term exercise therapy programs in the early stage after injury.

METHODS

One-hundred patients were included in a 5-week progressive exercise therapy program, within 3 months after injury. Knee function before and after completion of the program was evaluated from isokinetic quadriceps and hamstrings muscle strength tests, 4 single-leg hop tests, 2 different self-assessment questionnaires, and a global rating of knee function. A 2-way mixed-model analysis of variance was conducted to evaluate changes from pretest to posttest for the limb symmetry index for muscle strength and single-leg hop tests, and the change in scores for the patient-reported questionnaires. In addition, absolute values and the standardized response mean for muscle strength and single-leg hop tests were calculated at pretest and posttest for the injured and uninjured limb. Adverse events during the 5-week period were recorded.

RESULTS

The progressive 5-week exercise therapy program led to significant improvements (P<.05) in knee function from pretest to posttest both for patients classified as potential copers and noncopers. Standardized response mean values for changes in muscle strength and single-leg hop performance from pretest to posttest for the injured limb were moderate to strong (0.49-0.84), indicating the observed improvements to be clinically relevant. Adverse events occurred in 3.9% of the patients.

CONCLUSION

Short-term progressive exercise therapy programs are well tolerated and should be incorporated in early-stage ACL rehabilitation, either to improve knee function before ACL reconstruction or as a first step in further nonoperative management.

LEVEL OF EVIDENCE

Therapy, level 2b.

New developments in osteoarthritis. Prevention of injury-related knee osteoarthritis: opportunities for the primary and secondary prevention of knee osteoarthritis

Where risk factors have been identified in knee and hip osteoarthritis (OA), with few exceptions, no prevention strategies have proven beneficial. The major risk factors for knee OA are advanced age, injury and obesity. However, there is limited or no evidence that they are modifiable or to what degree modifying them is effective in preventing development of knee OA or in preventing symptoms and progressive disease in persons with early OA. The notable exception is the growing epidemic of (sports) injury related knee OA. This review details the biological and clinical data indicating the efficacy of interventions targeting neuromuscular and biomechanical factors that make this subset of OA an attractive public health target, and highlights research opportunities for the future.

Outcome of knee injuries in general practice: 1-year follow-up

BACKGROUND

Knee injuries may lead to pain and to functional limitations in the activities of daily living. Patients with knee injuries are frequently seen in general practice; however, the outcome and management in these patients is not known.

AIM

To assess the outcome and management of knee injuries at 12 months' follow-up in general practice.

DESIGN OF STUDY

A prospective observational cohort study with a 1-year follow-up.

SETTING

Primary health care.

METHOD

Adult patients consulting their GP after knee injury (n = 134) participated in the cohort. A magnetic resonance imaging scan was carried out and patients were diagnosed as either no lesion or an isolated meniscal tear, an isolated collateral or cruciate ligament lesion, or a combination. Follow-up questionnaires were filled in up to 12 months' follow-up.

RESULTS

At 12 months' follow-up, 34 patients reported full recovery and 67 patients reported major improvement. At baseline, 37 patients (28%) were referred to physical therapy and 17 patients (13%) were referred to secondary care. During 1 year of follow-up, another 21 referrals to physical therapy and 11 referrals to secondary care took place. The pain severity decreased the most, and the Lysholm knee score increased in the majority of patients during the first 3 months after injury. In total, 18 arthroscopies were performed in 15 patients. One patient underwent an anterior cruciate ligament reconstruction.

CONCLUSION

The vast majority of patients report clinically relevant recovery. There is no clear difference in outcomes between patients with meniscal tears or ligament lesions and patients without these diagnoses.