Report of the Primary Outcomes for Gait Mechanics in Men of the ACL-SPORTS Trial: Secondary Prevention With and Without Perturbation Training Does Not Restore Gait Symmetry in Men 1 or 2 Years After ACL Reconstruction

The Nature of Rehabilitation Programs to Improve Musculoskeletal, Biomechanical, Functional, and Patient-Reported Outcomes in Athletes With ACL Reconstruction: A Scoping Review

CONTEXT

After anterior cruciate ligament (ACL) reconstruction (ACLR), athletes commonly undergo prolonged rehabilitation (eg, 9-12 months), but few actually return to preinjury sports activities. The nature (composition, configuration) of an ACL rehabilitation program (ACL-RP) is an important factor in determining rehabilitation outcomes; however, details about the nature of ACL-RPs are reported inconsistently in research studies. To guide future research reporting to support clinical translation and implementation of ACL-RPs, it is necessary to describe the nature, reporting, and outcomes of ACL-RPs in the current literature.

OBJECTIVE

The purpose of this scoping review was to understand the nature and reporting of various ACL-RPs that address musculoskeletal, biomechanical, functional, or patient-reported outcome measures in adult and pediatric athletes with ACLR.

DATA SOURCES

Articles were selected from searches in 5 electronic databases (PubMed, EbscoHost [MEDLINE, SportDiscus, CINAHL Plus], PROQuest, Cochrane, and Embase).

STUDY SELECTION

Studies were included if they evaluated a post-ACL-RP that implemented strength, balance, plyometric, change of direction running, and/or agility running and included self-reported physical function, quality of life, or pain outcomes.

STUDY DESIGN

Scoping review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) guidelines.

LEVEL OF EVIDENCE

Level 4.

DATA EXTRACTION

Data were extracted and synthesized to evaluate the reporting of acute program variables (APVs) and exercise descriptors (EDs); 17 studies were included in the final synthesis.

RESULTS

Studies reported between 0% and 67% of the APVs and EDs combined. Only 2 studies were considered to have adequate reporting of both APVs and EDs.

CONCLUSION

Inadequate reporting of APVs and EDs in past studies restricts the translation and implementation of existing research-based ACL-RPs to present-day clinical contexts.

Individuals early after anterior cruciate ligament reconstruction show intact motor learning of step length via the split-belt treadmill

BACKGROUND

Rupturing the anterior cruciate ligament is an orthopedic injury that results in neuromuscular impairments affecting sensory input to the central nervous system. Traditional physical therapy after anterior cruciate ligament reconstruction aims to rehabilitate orthopedic impairments but fails to address asymmetric gait mechanics that are present post-operatively and are linked to the development of post-traumatic osteoarthritis. A first step towards developing gait interventions is understanding if individuals after anterior cruciate ligament reconstruction have the capacity to learn new walking mechanics.

METHODS

The split-belt treadmill offers a task-specific approach to examine neuromuscular adaptations in patients after injury. The potential for changing spatiotemporal gait mechanics via split-belt treadmill adaptation has not been tested early after anterior cruciate ligament reconstruction; nor has the ability to retain and transfer newly learned gait mechanics. Therefore, we used a split-belt treadmill paradigm to compare gait adaptation, retention, and transfer to overground walking between 15 individuals 3-9 months after anterior cruciate ligament reconstruction and 15 matched control individuals.

FINDINGS

Results suggested individuals after anterior cruciate ligament reconstruction were able to adapt and retain step length symmetry changes as well as controls. There was also evidence of partial transfer to overground walking, similar to controls.

INTERPRETATION

Despite disruption in afferent feedback from the joint, individuals early after anterior cruciate ligament reconstruction can learn a new gait pattern using sensorimotor adaptation, retain, and partially transfer the learned gait pattern. This may be a critical time to intervene with gait-specific interventions targeting post-operative gait asymmetries.

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.

Female Athletes With Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction

BACKGROUND

Approximately 1 in 4 athletes returning to sports will sustain a second anterior cruciate ligament (ACL) injury. Psychological factors related to kinesiophobia, confidence, and psychological readiness are associated with second ACL injury; however, the evidence is conflicting.

HYPOTHESIS

Athletes who sustain a second ACL injury (ie, graft rupture or contralateral ACL rupture) within 2 years of ACL reconstruction (ACLR) would have greater kinesiophobia, less confidence, and lower psychological readiness prior to return to sport (RTS) compared with athletes who do not sustain a second ACL injury.

STUDY DESIGN

Secondary analysis of a prospective randomized trial.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 39 female Level I/II athletes completed the following measures after postoperative rehabilitation and a 10-session RTS and second ACL injury prevention program: ACL Return to Sport after Injury (ACL-RSI) scale, the 11-item Tampa Scale of Kinesiophobia (TSK-11), and question 3 on the Knee injury and Osteoarthritis Outcome Score (KOOS) quality of life (QoL) subscale. Athletes were dichotomized based on whether they sustained a second ACL injury within 2 years of ACLR or not. Independent t tests determined group differences in TSK-11, KOOS-QoL, ACL-RSI, and the 3 individual components of the ACL-RSI (ie, emotions, confidence, risk appraisal).

RESULTS

Nine athletes sustained a second ACL injury (4 graft ruptures and 5 contralateral ACL ruptures). The group that sustained a second ACL injury had higher scores on the ACL-RSI (P = 0.03), higher on the risk appraisal questions of the ACL-RSI (P < 0.01), and met RTS criteria sooner than athletes who did not (P = 0.04). All second ACL injuries occurred in athletes who underwent primary ACLR with hamstring tendon autografts.

CONCLUSION

Athletes who sustained a second ACL within 2 years of ACLR had a more positive psychological outlook, higher scores on the specific questions related to the risk appraisal construct of the ACL-RSI, and met RTS criteria sooner than athletes who did not sustain a second ACL injury.

CLINICAL RELEVANCE

Counseling athletes about delaying RTS to reduce the risk of second ACL injury may be especially important in athletes who display high psychological readiness and meet RTS criteria sooner.

Erector Spinae Muscle Activation During Forward Movement in Individuals With or Without Chronic Lower Back Pain: A Systematic Review and Meta-analysis

Objective

To investigate the differences between erector spinae muscle activation in healthy individuals and patients with Chronic Lower Back Pain (CLBP) by conducting (a) systematic review and (b) meta-analysis.

Data Sources

PubMed, ScienceDirect, SPORTDiscus, and Google Scholar were used to conduct the searches, which included studies up to the 31st of March 2023 with no start date specified.

Study Selection

Any study otherwise meeting eligibility criteria was included if it reported either (1) a standard mean difference effect size; or (2) the means, SDs, and sample sizes for both the patient group and the comparator group.

Data Extraction

A total of 7 case control trials were used for the systematic review and meta-analysis.

Data Synthesis

The systematic review and meta-analysis revealed that total standardized mean difference in erector spinae muscle activation between healthy individuals vs patients with CLBP expressed in % maximum voluntary isometric contraction was 0.48 (95% confidence interval=0.21-0.74; P<.001) with the heterogeneity being I2=0% (P=.890). The electromyography (EMG) outputs showed significant differences in activation levels between the healthy and CLBP cohorts (P<.001).

Conclusions

A small effect size was found in the meta-analysis. The muscle activation levels of the erector spinae during forward propulsion were higher in CLBP individuals compared with healthy cohorts. The findings provide more clarity about the muscles that were the focus of previous research, what procedures were used to evaluate muscular contributions and what speeds the participants were moving at during the test sessions. Given the limited methodological quality of the included studies, the findings should be interpreted with caution. Future research should evaluate the effect of other factors such as walking distance and any changes in walking surfaces and gradients (ie, non-flat surfaces).

Secondary Anterior Cruciate Ligament Injury Prevention Training in Athletes: What Is the Missing Link?

After reconstruction, the return to full competition rate of athletes is low, while the re-injury rate remains high despite the completion of a rehabilitation programme. Primary ACL prevention programmes are well developed, yet few research papers focus on secondary ACL injury prevention. The aim of current review is to determine if current ACL secondary prevention training has a positive influence on the re-injury rate, the clinical or functional outcomes, or the risk of re-injury in athletes. Studies investigating secondary prevention of ACL were searched in PubMed and EBSCOhost, followed by a review of the references in the identified articles. The existing evidence suggests that neuromuscular training, eccentric strengthening, and plyometric exercises may have a potential impact on improving biomechanical, functional, and psychological outcomes in athletes; however, the studies on the prevention of second ACL injury in athletes is scarce and inconclusive. Future research is needed to investigate the effectiveness of secondary ACL prevention in reducing the re-injury rates. (PROSPERO Registration number: CRD42021291308).

Patellofemoral contact forces and knee gait mechanics 3 months after ACL reconstruction are associated with cartilage degradation 24 months after surgery

OBJECTIVE

Evaluate patellofemoral cartilage health, as assessed by quantitative magnetic resonance imaging (qMRI) T2 relaxation times, 24-months after ACL reconstruction (ACLR) and determine if they were associated with patellofemoral contact forces and knee mechanics during gait 3 months after surgery.

DESIGN

Thirty individuals completed motion analysis during overground walking at a self-selected speed 3 months after ACLR. An EMG-driven neuromusculoskeletal model was used to determine muscle forces, which were then used in a previously described model to estimate patellofemoral contact forces. Biomechanical variables of interest included peak patellofemoral contact force, peak knee flexion angle and moment, and walking speed. These same participants underwent a sagittal bilateral T2 mapping qMRI scan 24-months after surgery. T2 relaxation times were estimated for both patellar and trochlear cartilage. Paired t-tests were used to compare T2 relaxation times between limbs while Pearson correlations and linear regressions were utilized to assess the association between the biomechanical variables of interest and T2 relaxation times.

RESULTS

Prolonged involved limb trochlear T2 relaxation times (vs uninvolved) were present 24-months after surgery, indicating worse cartilage health. No differences were detected in patellar cartilage. Significant negative associations were present within the involved limb for all the biomechanical variables of interest 3 months after ACLR and trochlear T2 relaxation times at 24-months. No associations were found in patellar cartilage or within the uninvolved limb.

CONCLUSIONS

Altered involved limb trochlear cartilage health is present 24-months after ACLR and may be related to patellofemoral loading and other walking gait mechanics 3 months after surgery.

Mechanical Factors Contributing to Altered Knee Extension Moment during Gait after ACL Reconstruction: A Longitudinal Analysis

PURPOSE

This study aimed to comprehensively examine the extent to which knee flexion angle at initial contact, peak knee flexion angle, and vertical ground reaction force (vGRF) contribute to knee extension moments during gait in individuals with anterior cruciate ligament (ACL) reconstruction.

METHODS

Overground gait biomechanics were evaluated in 26 participants with ACL reconstruction at three time points (about 2, 4, and 6 months after the surgery). Knee flexion angle at initial contact, peak knee flexion angle, peak vGRF, and peak knee extension moment were calculated for each limb during the early stance phase of gait for all three time points. A change score from baseline (time point 2 - time point 1 and time point 3 - time point 1) along with limb symmetry values (ACL - non-ACL limb values) was also calculated for these variables. Multiple linear regressions utilizing classical and Bayesian interference methods were used to determine the contribution of knee flexion angle and vGRF to knee extension moment during gait.

RESULTS

Peak knee flexion angle and peak vGRF positively contributed to knee extension moment during gait in both the reconstructed ( R2 = 0.767, P < 0.001) and nonreconstructed limbs ( R2 = 0.815, P < 0.001). Similar results were observed for the symmetry values ( R2 = 0.673, P < 0.001) and change scores ( R2 = 0.731-0.883; all P < 0.001), except that the changes in knee flexion angle at initial contact also contributed to the model using the change scores in the nonreconstructed limb (time point 2 - time point 1: R2 = 0.844, P < 0.001; time point 3 - time point 1: R2 = 0.883, P < 0.001). Bayesian regression evaluating the likelihood of these prediction models showed that there was decisive evidence favoring the alternative model over the null model (all Bayes factors >1000). Standardized β coefficients indicated that changes in knee flexion angle had a greater impact (>2×) on knee extension moments than vGRF at both time points in both limbs ( βvGRF = 0.204-0.309; βkneeflexion = 0.703-0.831).

CONCLUSIONS

The findings indicate that both knee flexion angle and peak vGRF positively contribute to altered knee extension moments during gait, but the contribution of knee flexion angle is much greater than vGRF. Therefore, treatment strategies targeting these variables may improve knee loading after ACL reconstruction.

Bone-Patellar Tendon-Bone Autograft Harvest Prolongs Extensor Latency during Gait 2 yr after ACLR

PURPOSE

Bone-patellar tendon-bone (BPTB) graft harvest for anterior cruciate ligament reconstruction alters patellar tendon properties, which inflict poor quadriceps neuromuscular function. BPTB autografts are associated with higher rates of posttraumatic osteoarthritis, which in turn is associated with pathological gait. The purpose of this study was to investigate the latency between the time of peak quadriceps activity and the peak knee flexion moment during gait, between those with BPTB grafts ( n = 23) and other graft types (hamstring autograft or allografts, n = 54), 5 ± 2 months and 2 yr (25 ± 3 months) after anterior cruciate ligament reconstruction. We hypothesized that longer latencies would be observed in the BPTB graft group in the involved limb. We expected latencies to shorten over time.

METHODS

Knee moments and quadriceps EMG were collected during gait, and vastus medialis, vastus lateralis, rectus femoris (RF), and quadriceps latencies were calculated. Linear mixed-effects models were used to compare latencies between graft types and over the two time points.

RESULTS

The main effects of graft type were observed for vastus medialis ( P = 0.005) and quadriceps ( P = 0.033) latencies with the BPTB graft group demonstrating longer latencies. No main effects of graft type were observed for vastus lateralis ( P = 0.051) and RF ( P = 0.080) latencies. Main effects of time were observed for RF latency ( P = 0.022).

CONCLUSIONS

Our hypothesis that the BPTB graft group would demonstrate longer extensor latency was supported. Contrary to our second hypothesis, however, latency only improved in RF and regardless of graft type, indicating that neuromuscular deficits associated with BPTB grafts may persist 2 yr after surgery. Persistent deficits may be mediated by changes in the patellar tendon's mechanical properties. Graft-specific rehabilitation may be warranted to address the long-term neuromechanical deficits that are present after BPTB graft harvest.

Functional Resistance Training After Anterior Cruciate Ligament Reconstruction Improves Knee Angle and Moment Symmetry During Gait: A Randomized Controlled Clinical Trial

PURPOSE

The purpose of this study was to determine 1) whether progressive functional resistance training (FRT) during walking would improve knee biomechanical symmetry after anterior cruciate ligament (ACL) reconstruction and 2) whether the mode of delivery of FRT would have a differential effect on symmetry.

METHODS

Thirty individuals who underwent primary ACL reconstruction at a single institution volunteered for this study. Participants were randomized into one of three groups: 1) BRACE, 2) BAND, or 3) CONTROL. The BRACE group received FRT with a novel robotic knee brace along with real-time kinematic feedback. The BAND group received FRT with a custom resistance band device along with real-time kinematic feedback. The CONTROL group received only real-time kinematic feedback. Participants in all groups received training (2-3/week for 8 weeks) while walking on a treadmill. Knee angle and moment symmetry were calculated immediately prior to beginning the intervention and within 1 week of completing the intervention. Statistical Parametric Mapping was used to assess differences in biomechanical symmetry between groups across time.

RESULTS

There was a significant interaction in knee moment symmetry from 21 and 24% of the stance phase (P = .046), in which the BAND group had greater improvements following training compared with both BRACE (P = .043) and CONTROL groups (P = .002). There was also a significant time effect in knee angle symmetry from 68 to 79% of the stance phase (P = .028) and from 97 to 100% of the swing phase (P = .050) in which only the BRACE group showed significant improvements after the intervention (stance: P = .020 and swing: P < .001).

CONCLUSION

The results of this randomized controlled clinical trial indicate that 8 weeks of progressive FRT during treadmill walking in individuals with ACL reconstruction improves knee angle and moment symmetry during gait. The findings suggest that FRT could serve as a potential therapeutic adjuvant to traditional rehabilitation after ACL reconstruction and can help restore knee joint biomechanical symmetry.

LEVEL OF EVIDENCE

Level II, randomized controlled trial.

Environmental Risk Factors for Osteoarthritis: The Impact on Individuals with Knee Joint Injury

Osteoarthritis is a debilitating chronic condition involving joint degeneration, impacting over 300 million people worldwide. This places a high social and economic burden on society. The knee is the most common joint impacted by osteoarthritis. A common cause of osteoarthritis is traumatic joint injury, specifically injury to the anterior cruciate ligament. The purpose of this review is to detail the non-modifiable and modifiable risk factors for osteoarthritis with particular focus on individuals after anterior cruciate ligament injury. After reading this, health care providers will better comprehend the wide variety of factors linked to osteoarthritis.

Factors Influencing Treatment Outcome and Proprioception after Electrocoagulation of the Femoral Insertion of the Anterior Cruciate Ligament

(1) Background: Studies have established that exercises shaping the sense of deep sensation are an important element of medical rehabilitation of patients after vaporization of the femoral insertion of the anterior cruciate ligament and affect the restoration of correct movement patterns, thus reducing the risk of injuries. The aim of this study was to determine the factors influencing the treatment outcome and deep-feeling function after applying a specific rehabilitation scheme 12 weeks after anterior cruciate ligament electrocoagulation surgery. (2) Methods: The study group consisted of 41 patients after partial rupture of the anterior cruciate ligament, who underwent electrocoagulation of the femoral cruciate ligament attachment and microfracture of the femoral attachment area. All patients were operated on by the same surgeon and then rehabilitated according to the same medical rehabilitation protocol. The anthropometric and clinical data were collected through an anterior drawer test, Lachman test, assessment of the range of movements in the knee joint, muscle strength test, Unterberger test and Lysholm questionnaire. The assessment was performed before the surgery, and then on days 7-10, after 6 and 12 weeks of rehabilitation treatment. (3) Results: Statistical improvement of the parameters was demonstrated by strength of the quadriceps and hamstrings muscle, the Unterberger test, and the Lysholm scale after surgery. A negative correlation was found between the Unterberger test and Lysholm scale at the end of the research period and it differed depending on the gender and the dominant limb. The Lysholm scale and muscle strength were independent of sex, dominant extremity and associated damage of the meniscus and cartilage. The Lysholm scale 6 weeks after surgery negatively correlated with BMI. (4) Conclusions: Stability of the knee joint and improvement of proprioception were demonstrated 12 weeks after treatment with an ACL electrocoagulation and rehabilitation regimen. The factors contributing to a better treatment outcome were greater muscle strength, less thigh asymmetry, better sense of depth, younger age and lower body weight.

Males and females have different muscle activity patterns during gait after ACL injury and reconstruction

Kinematic and kinetic changes following anterior cruciate ligament (ACL) rupture and reconstruction (ACLR) have been fundamental to the understanding of mechanical disrupted load as it contributes to the development of posttraumatic osteoarthritis. These analyses overlook the potential contribution of muscle activity as it relates to the joint loading environment. Males and females classified as non-copers present with unique knee kinematics and kinetics after ACL injury. The purpose of this study was to perform sex-specific analyses in these individuals to explore muscle activity timing during gait after ACL rupture. Thirty-nine participants (12 females, 27 males) were enrolled. Muscle activity during gait was evaluated before and after pre-operative physical therapy, and six months after ACLR. Surface electromyography data were evaluated to determine timing (e.g., the time the muscle activity begins ('On') and ends ('Off')) for seven muscles: vastus lateralis and medialis (VL, VM), lateral and medial hamstrings (LH, MH), lateral and medial gastrocnemius (LG, MG), and soleus (SOL). General linear models with generalized estimating equations detected the effects of limb and time for muscle activity timing. Males presented with more limb asymmetries before and after pre-operative PT in the VL On (p < 0.001) and Off (p = 0.007), VM On and Off (p < 0.001), and MH off (p < 0.001), but all limb differences resolved by six months post ACLR. Changes in muscle activity in males were pervasive over time in both limbs. Females presented with no interlimb differences pre-operatively, and only involved limb VL off (p = 0.027) and VM off (p = 0.003) and the LH off in both limbs (p < 0.038) changed over time. Our data indicate that inter-limb differences in muscle activity across time points and changes in muscle activity timing over the course of physical therapy were sex specific. Males presented with more inter-limb differences in muscle activity across time points, and females presented with fewer asymmetries before and after pre-operative physical therapy. These data support that sex-specific adaptations should be taken into consideration when assessing biomechanical changes after ACLR.

The effect of proprioception training on knee kinematics after anterior cruciate ligament reconstruction: A randomized control trial

BACKGROUND

Proprioception is essential for the normal movement of knee joints. How proprioception training affects the postoperative knee functional recovery after anterior cruciate ligament (ACL) reconstruction remains unknown.

OBJECTIVE

This study investigated the effect of proprioception training on the knee joint kinematics of patients after ACL reconstruction (ACLR).

METHODS

The randomized controlled study was performed at the Department of Orthopaedics and Traumatology of Guangdong Provincial People's Hospital between December 2019 and April 2021. Forty-five patients who underwent ACLR were randomly divided into a proprioception group (n= 23) and a control group (n= 22). The patients were randomly divided into an experimental group and a control group according to whether the final digits of their ID numbers were odd or even. All patients followed a common postoperative rehabilitation program. The outcome measures included the patients Lysholm scores, hop distances, and knee kinematics during unanticipated jump-cut maneuvering measured at different follow-up times. Knee joint kinematics were described as the positional and orientational changes of the femur relative to the tibia.

RESULTS

After surgery, the proprioception group did not exhibit significantly higher hop distances than the control group at the 6-month (114.8 ± 19.0 vs. 105.9 ± 20.7 cm, p= 0.137, 95% CI: -3.13 to 22.03 cm) and 1-year follow-ups (143.1 ± 19.3 vs. 133.9 ± 26.2 cm, p= 0.216, 95% CI: -5.57 to 23.87 cm). For knee joint kinematics, the members of the proprioception training group exhibited significantly reduced knee abduction (valgus) angles and external rotation and significantly increased knee flexion compared to those in the common training group.

CONCLUSIONS

The results suggested that proprioceptive rehabilitation training enhances knee joint functional performance and shows altered knee joint kinematics in ACL-reconstructed populations during unanticipated jump-cut maneuvering compared with the common rehabilitation training.

Reduction of risk factors for ACL Re-injuries using an innovative biofeedback approach: A phase I randomized clinical trial

OBJECTIVES

Determine the safety and initial efficacy of a novel biofeedback intervention to improve landing mechanics in patients following anterior cruciate ligament reconstruction (ACLR).

METHODS

Forty patients post-ACLR (age: 16.9 ± 2.0 years) were randomly allocated to a biofeedback intervention or an attention control group. Patients in the biofeedback group completed 12 sessions over six-weeks that included bilateral unweighted squats with visual and tactile biofeedback. Patients in the control group completed a six-week educational program. Lower extremity mechanics were collected during a bilateral stop jump at baseline, six-weeks, and 12-weeks post-intervention. Linear mixed-effects models adjusted for sex and graft type determined the main effects of and interactions between group and time.

RESULTS

No group by time interaction existed for peak knee extension moment symmetry. A group by time interaction existed for peak vertical ground reaction force symmetry (p = 0.012), where patients in the biofeedback group had greater improvements in symmetry between baseline and post-intervention that were not maintained through the retention assessments.

CONCLUSION

This novel biofeedback program did not reduce risk factors for second ACL injuries. Future work could develop and test multidisciplinary interventions for reducing second ACL injury risk factors.

CLINICALTRIALS

GOV IDENTIFIER: (NCT03273673).

Knee joint biomechanics during gait improve from 3 to 6 months after anterior cruciate ligament reconstruction

Gait alterations after anterior cruciate ligament reconstruction (ACLR) are commonly reported and have been linked to posttraumatic osteoarthritis development. While knee gait alterations have been studied at several time points after ACLR, little is known about how these biomechanical variables change earlier than 6 months after surgery, nor is much known about how they differ over the entire stance phase of gait. The purpose of this study was to examine knee gait biomechanical variables over their entire movement pattern through stance at both 3 and 6 months after ACLR and to study the progression of interlimb asymmetry between the two postoperative time points. Thirty-five individuals underwent motion analysis during overground walking 3 (3.2 ± 0.5) and 6 (6.4 ± 0.7) months after ACLR. Knee biomechanical variables were compared between limbs and across time points through 100% of stance using statistical parametric mapping; this included a 2 × 2 (Limb × Time) repeated measures analysis of variance and two-tailed t-tests. Smaller knee joint angles, moments, extensor forces, and medial compartment forces were present in the involved versus uninvolved limb. Interlimb asymmetries were present at both time points but were less prevalent at 6 months. The uninvolved limb's biomechanical variables stayed relatively consistent over time, while the involved limb's trended toward that of the uninvolved limb. Statement of Clinical Significance: Interventions to correct asymmetrical gait patterns after ACLR may need to occur early after surgery and may need to focus on multiple parts of stance phase.

Perturbations during Gait: A Systematic Review of Methodologies and Outcomes

BACKGROUND

Despite extensive literature regarding laboratory-based balance perturbations, there is no up-to-date systematic review of methods. This systematic review aimed to assess current perturbation methods and outcome variables used to report participant biomechanical responses during walking.

METHODS

Web of Science, CINAHL, and PubMed online databases were searched, for records from 2015, the last search was on 30th of May 2022. Studies were included where participants were 18+ years, with or without clinical conditions, conducted in non-hospital settings. Reviews were excluded. Participant descriptive, perturbation method, outcome variables and results were extracted and summarised. Bias was assessed using the Appraisal tool for Cross-sectional Studies risk of bias assessment tool. Qualitative analysis was performed as the review aimed to investigate methods used to apply perturbations.

RESULTS

644 records were identified and 33 studies were included, totaling 779 participants. The most frequent method of balance perturbation during gait was by means of a treadmill translation. The most frequent outcome variable collected was participant step width, closely followed by step length. Most studies reported at least one spatiotemporal outcome variable. All included studies showed some risk of bias, generally related to reporting of sampling approaches. Large variations in perturbation type, duration and intensity and outcome variables were reported.

CONCLUSIONS

This review shows the wide variety of published laboratory perturbation methods. Moreover, it demonstrates the significant impact on outcome measures of a study based on the type of perturbation used.

REGISTRATION

PROSPERO ID: CRD42020211876.

Identifying Gait Pathology after ACL Reconstruction Using Temporal Characteristics of Kinetics and Electromyography

PURPOSE

Asymmetrical gait mechanics after anterior cruciate ligament reconstruction (ACLR) are associated with the development of posttraumatic knee osteoarthritis. Current measures of gait mechanics have focused heavily on peak magnitudes of knee kinematics, kinetics, and joint contact forces but have seldom considered the rate of knee loading, cumulative knee load, or the timing of motor input surrounding peaks. The purpose of this study was to introduce and describe novel metrics of gait using temporal characteristics of kinetics and EMG to identify neuromuscular deficits of the quadriceps in patients after ACLR.

METHODS

Gait mechanics were assessed 6 months (n = 145) and 24 months (n = 116) after ACLR. External knee flexion rate of moment development (RMD) and knee flexion moment impulse (KFMI) leading up to the time of peak knee flexion moment (pKFM), peak RMD between initial contact to pKFM, and cumulative KFMI were calculated. Extensor latencies from the quadriceps, vastus medialis, vastus lateralis, and rectus femoris (time of pKFM - time of peak EMG activity) during the weight acceptance phase of gait were also calculated. Paired-sample t-tests (α = 0.05) were performed between limbs at both time points.

RESULTS

Slower RMD, smaller KFMI, and longer extensor latencies in the involved compared with uninvolved limb were observed across all measures at 6 months (P < 0.005). At 24 months, RMDpeak was slower, and KFMI50ms, KFMI100ms, and KFMItotal were lower in the involved limb (P < 0.003), but no other asymmetries were found.

CONCLUSIONS

Slower RMD, smaller KFMI, and prolonged extensor latencies may characterize neuromuscular deficits underlying aberrant gait mechanics early after ACLR. RMD, KFMI, and extensor latencies during gait should be considered in the future to quantify asymmetrical movement patterns observed after ACLR and as markers of recovery.

Anterior Cruciate Ligament Reconstruction Recovery and Rehabilitation: A Systematic Review

BACKGROUND

The success of anterior cruciate ligament (ACL) reconstruction is influenced by effective rehabilitation. Previously published, comprehensive systematic reviews evaluating rehabilitation after ACL reconstruction have studied Level-I and II evidence published through 2012. Interval studies continue to evaluate the efficacy of various rehabilitative modalities.

METHODS

A total of 824 articles from 2012 to 2020 were identified using multiple search engines. Fifty Level-I or II studies met inclusion criteria and were evaluated using the Consolidated Standards of Reporting Trials (CONSORT) criteria and National Institutes of Health (NIH) Study Quality Assessment Tools.

RESULTS

Accelerated rehabilitation can be effective for patients with semitendinosus-gracilis grafts. Blood flow restriction (BFR) training with high-intensity exercise is not effective for ACL reconstruction recovery. Postoperative bracing does not offer any advantages or improve limb asymmetry. Cryotherapy is an effective analgesic when used perioperatively. The early introduction of open kinetic chain exercises may improve ACL reconstruction outcomes, and high-intensity plyometric exercise is not effective. Estimated pre-injury capacity (EPIC) levels may be more accurate than the Limb Symmetry Index (LSI) when using functional test results to predict reinjury rates, and hip external rotation strength may be the most accurate predictor of the hop test performance. Nerve blocks can provide postoperative analgesia with minimal complication risk. Neuromuscular electrical stimulation is effective when used independently and in combination with rehabilitative exercises. Psychological readiness should be evaluated both objectively and subjectively before allowing patients to safely return to sport. Electromyography biofeedback may help to regain muscular function, and whole-body vibration therapy can improve postural control. Supervised rehabilitation is more effective than unsupervised rehabilitation.

CONCLUSIONS

Various rehabilitative modalities following ACL reconstruction are effective in improving surgical outcomes and return-to-sport rates. Further evidence and improved study design are needed to further validate modalities including accelerated rehabilitation, BFR training, functional testing, and return-to-sport criteria.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Principles for Postoperative Rehabilitation and Return to Sport for Athletes Undergoing Anterior Cruciate Ligament Reconstruction

Despite advancements in our understanding of anterior cruciate ligament (ACL) injury prevention and nonsurgical management, ACL reconstruction continues to occur at an alarming rate. Among athletic patients, individuals participating in basketball, soccer, and football have the highest incidence of ACL injury, often requiring surgical intervention. To ensure the optimal treatment strategy for return to sport and prevention of secondary graft re-tear, it is important to tailor to the specific demands of the injured athlete and apply evidence-based best practices and rehabilitation principles. The purpose of this review is to provide readers with a brief background regarding ACL injuries, a focused review of clinical outcome studies after ACL reconstruction, and an updated framework with expert-guided recommendations for postoperative rehabilitation and return to sporting activity. Currently, there is no gold standard for rehabilitation after ACL reconstruction, highlighting the need for robust studies evaluating the best modalities for athlete rehabilitation, as well as determining the efficacy of new tools for improving therapy including blood flow restriction therapy and neuromuscular electrical stimulation. Based on clinical experience, a renewed focus on objective, criteria-based milestones may maximize the ability of return to preinjury levels of athletic function.

Psychosocial factors 3-months after anterior cruciate ligament reconstruction predict 6-month subjective and objective knee outcomes

The objective of the study was to determine if psychological readiness for sport and knee self-efficacy assessed early (3 months) after anterior cruciate ligament reconstruction (ACLR) are predictive of self-reported functional outcomes, quadriceps strength, and knee mechanics while running at the time of return to sport training (6 months). Thirty athletes with unilateral ACLR completed the ACL Return to Sport after Injury (ACL-RSI) and Knee Self-Efficacy Scale (K-SES) 3 months after ACLR and completed self-reported functional outcomes, isometric quadriceps strength testing, and three-dimensional running gait analysis 6 months after ACLR. The 3-month ACL-RSI significantly correlated with the 6-month International Knee Documentation Committee (IKDC; r = 0.565, p = 0.001), Knee Injury and Osteoarthritis Outcome Score (KOOS) sport/recreational activities (KOOS_Sport ; r = 0.548, p = 0.002) and quality of life (KOOS_QoL ; r = 0.431, p = 0.017), and quadriceps strength (r = 0.528, p = 0.003). The 3-month K-SES significantly correlated with the 6-month IKDC (r = 0.528, p = 0.003), KOOS_Sport (r = 0.430, p = 0.018), KOOS_QoL (r = 0.411, p = 0.024), quadriceps strength (r = 0.465, p = 0.010), and knee flexion excursion (r = 0.472, p = 0.008). With multivariate modeling, both the ACL-RSI and K-SES were predictive of the IKDC (R²  = 0.411; p = 0.001). Only the ACL-RSI was predictive of the KOOS_Sport (R²  = 0.300; p = 0.002), KOOS_QoL (R²  = 0.186; p = 0.017), and quadriceps strength (R²  = 0.279; p = 0.003), whereas only the K-SES was predictive of knee flexion excursion (R²  = 0.173; p = 0.022). Athletes with greater psychological readiness for sport and knee self-efficacy at 3 months demonstrated higher scores on self-reported functional outcomes, greater quadriceps strength, and greater knee flexion excursion at 6 months after ACLR. This study indicates that psychosocial measures may be important to include into early post-surgical evaluations to help guide and facilitate interventions to restore subjective and objective knee function.

Knee Biomechanical Deficits During a Single-Leg Landing Task Are Addressed With Neuromuscular Training in Anterior Cruciate Ligament-Reconstructed Athletes

OBJECTIVE

Faulty neuromuscular and biomechanical deficits of the knee are nearly ubiquitous in athletes after anterior cruciate ligament (ACL) reconstruction (ACLR). Knee biomechanical deficits are directly associated with an increased risk of second ACL injury, which typically occurs during a sports-related movement on a single limb. To date, the biomechanical effects of a neuromuscular training (NMT) program on knee biomechanics during a single-leg landing task have not been investigated.

DESIGN

Prospective Cohort Study.

SETTING

Controlled laboratory setting.

PARTICIPANTS

Eighteen ACLR and 10 control athletes.

INTERVENTIONS

Neuromuscular training.

MAIN OUTCOME MEASURES

Knee kinematics and kinetics.

RESULTS

There were no significant interactions of session and limb (P > 0.05) for the athletes with ACLR after training. However, there were several significant main effects of session (P < 0.05) for knee kinematics and kinetics during the single-leg landing task. After training, the athletes with ACLR landed with greater knee flexion angles, decreased knee abduction angles, increased knee flexion range of motion, and decreased knee excursion. Also, the ACLR athletes landed with lower knee flexion moments, greater knee adduction moments, and lower peak vertical ground reaction force. Post-training comparison of the ACLR and control cohorts found no significant interactions of group and limb (P > 0.05) and only a significant main effect of group (P < 0.05) for frontal plane knee angle at initial contact. The athletes with ACLR landed with greater knee adduction angles than the control group.

CONCLUSIONS

Deficits in knee biomechanics that are associated with an increased risk of ACL injury are attenuated after completion of this NMT program.

Sex and mechanism of injury influence knee joint loading symmetry during gait 6 months after ACLR

Early-onset knee osteoarthritis (OA) is associated with gait asymmetries after anterior cruciate ligament reconstruction (ACLR). Women have higher risks of sustaining non-contact injuries, and are more likely to present with aberrant movement patterns associated with the mechanism of injury (MOI). We hypothesized that sex and MOI would influence gait after ACLR. Seventy participants, grouped by sex and MOI, completed biomechanical testing during over-ground walking when they had full knee range of motion, trace or less knee effusion, greater than 80% quadriceps strength limb symmetry index, ability to hop on each leg without pain, and initiated running. Bilateral knee kinetics, kinematics, and joint contact forces were compared using mixed-model analysis of variance (α = .05). There was a three-way interaction effect of sex × MOI × limb for peak medial compartment contact force (P = .002), our primary outcome measure previously associated with OA development. Men with non-contact injuries walked with asymmetry characterized by underloading of the involved limb. Men with contact injuries walked with the most symmetrical loading. In women, no clear pattern emerged based on MOI. Targeting, and possibly prioritizing interventions for athletes who present with gait asymmetries after ACLR based on sex and MOI, may be necessary to optimize outcomes. Statement of Clinical Significance: Sex and MOI may influence walking mechanics, and could be considered in future interventions to target gait symmetry, as a response to interventions may vary based on differences in sex and MOI.

Association between Kinesiophobia and Gait Asymmetry after ACL Reconstruction: Implications for Prevention of Reinjury

Gait asymmetries have been documented in individuals after anterior cruciate ligament (ACL) reconstruction (ACLR). The relationship between gait asymmetry and associated psychological factors, however, is not yet known. This study aimed to examine the relationship between kinesiophobia (fear of reinjury) and asymmetry of vertical ground reaction force (vGRF) and lower-extremity muscular activity in individuals after ACLR during gait. Twenty-eight males with a history of ACLR participated in the study. Force plate and surface electromyography was used to record peak vGRF and muscular activity. The Tampa Scale of Kinesiophobia (TSK-11) was used to measure kinesiophobia. Spearman’s rank correlations analysis was used to examine the relationship between TSK-11 scores and both gait asymmetry variables. There was a significant positive relationship between TSK-11 and asymmetry of the second peak of vGRF (r_s = 0.531, p = 0.002). In addition, there was a significant positive association between asymmetry of rectus femoris activity (r_s = 0.460, p = 0.007) and biceps femoris activity (r_s = 0.429, p = 0.011) in the contact phase. Results revealed a significant relationship between kinesiophobia and asymmetry in muscle activity and vGRF in different phases of the gait cycle. Interventions addressing kinesiophobia early in the rehabilitation after ACLR may support the restoration of gait symmetry, facilitate a more rapid return to sport, and reduce the risk of ACL reinjury.

Neuromuscular Training Improves Biomechanical Deficits at the Knee in Anterior Cruciate Ligament-Reconstructed Athletes

OBJECTIVE

Athletes who return to sport after anterior cruciate ligament reconstruction (ACLR) demonstrate persistent biomechanical and neuromuscular deficits of the knee. There is limited evidence on what effect a neuromuscular training (NMT) program has on knee biomechanics in a cohort of athletes with ACLR. Therefore, the primary aim of this study was to quantify the effect of an NMT program on knee biomechanics in a cohort of ACLR athletes. Second, the post-training knee biomechanics were compared between the cohort of ACLR and control athletes.

DESIGN

Cohort study.

SETTING

Controlled laboratory setting.

PARTICIPANTS

Eighteen athletes with ACLR and 10 control athletes.

INTERVENTIONS

Neuromuscular training.

MAIN OUTCOME MEASURES

Knee kinematics and kinetics during a double-limb jump-landing task.

RESULTS

There were no significant interactions (P > 0.05) observed for the athletes with ACLR. However, there was a significant main effect of biomechanics testing session (P < 0.05) for knee flexion angle and moments; athletes with ACLR demonstrated greater knee flexion angle and lower knee flexion moment during the post-training biomechanics testing session. Post-training comparison between the ACLR and control athletes demonstrated no significant interactions (P > 0.05) between the groups. There was a significant main effect of group (P < 0.05) for knee frontal angle, as athletes with ACLR landed with greater knee adduction than the control athletes.

CONCLUSIONS

Significant improvements in knee sagittal plane biomechanical measures were observed after the NMT program by the athletes with ACLR. In addition, post-training comparison of the ACLR and control groups demonstrates comparable knee biomechanics.

Patients Walking Faster After Anterior Cruciate Ligament Reconstruction Have More Gait Asymmetry

BACKGROUND

Gait asymmetries after anterior cruciate ligament reconstruction (ACLR) may lead to radiographic knee osteoarthritis. Slower walking speeds have been associated with biomarkers suggesting cartilage breakdown. The relationship between walking speed and gait symmetry after ACLR is unknown.

HYPOTHESIS/PURPOSE

To determine the relationship between self-selected walking speeds and gait symmetry in athletes after primary, unilateral ACLR.

STUDY DESIGN

Secondary analysis of a clinical trial.

METHODS

Athletes 24±8 weeks after primary ACLR walked at self-selected speeds as kinematics, kinetics, and electromyography data were collected. An EMG-driven musculoskeletal model was used to calculate peak medial compartment contact force (pMCCF). Variables of interest were peak knee flexion moment (pKFM) and angle (pKFA), knee flexion and extension (KEE) excursions, peak knee adduction moment (pKAM), and pMCCF. Univariate correlations were run for walking speed and each variable in the ACLR knee, contralateral knee, and interlimb difference (ILD).

RESULTS

Weak to moderate positive correlations were observed for walking speed and all variables of interest in the contralateral knee (Pearson's r=.301-.505, p≤0.01). In the ACLR knee, weak positive correlations were observed for only pKFM (r=.280, p=0.02) and pKFA (r=.263, p=0.03). Weak negative correlations were found for ILDs in pKFM (r=-0.248, p=0.04), KEE (r=-.260, p=0.03), pKAM (r=-.323, p<0.01), and pMCCF (r=-.286, p=0.02).

CONCLUSION

Those who walk faster after ACLR have more asymmetries, which are associated with the development of early OA. This data suggests that interventions that solely increase walking speed may accentuate gait symmetry in athletes early after ACLR. Gait-specific, unilateral, neuromuscular interventions for the ACLR knee may be needed to target gait asymmetries after ACLR.

LEVEL OF EVIDENCE

III.

Quadriceps Strength Symmetry Does Not Modify Gait Mechanics After Anterior Cruciate Ligament Reconstruction, Rehabilitation, and Return-to-Sport Training

BACKGROUND

After anterior cruciate ligament (ACL) reconstruction (ACLR), biomechanical asymmetries during gait are highly prevalent, persistent, and linked to posttraumatic knee osteoarthritis. Quadriceps strength is an important clinical measure associated with preoperative gait asymmetries and postoperative function and is a primary criterion for return-to-sport clearance. Evidence relating symmetry in quadriceps strength with gait biomechanics is limited to preoperative and early rehabilitation time points before return-to-sport training.

PURPOSE/HYPOTHESIS

The purpose was to determine the relationship between symmetry in isometric quadriceps strength and gait biomechanics after return-to-sport training in athletes after ACLR. We hypothesized that as quadriceps strength symmetry increases, athletes will demonstrate more symmetric knee joint biomechanics, including tibiofemoral joint loading during gait.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Of 79 athletes enrolled in the ACL-SPORTS Trial, 76 were participants in this study after completing postoperative rehabilitation and 10 return-to-sport training sessions (mean ± SD, 7.1 ± 2.0 months after ACLR). All participants completed biomechanical walking gait analysis and isometric quadriceps strength assessment using an electromechanical dynamometer. Quadriceps strength was calculated using a limb symmetry index (involved limb value / uninvolved limb value × 100). The biomechanical variables of interest included peak knee flexion angle, peak knee internal extension moment, sagittal plane knee excursion at weight acceptance and midstance, quadriceps muscle force at peak knee flexion angle, and peak medial compartment contact force. Spearman rank correlation (ρ) coefficients were used to determine the relationship between limb symmetry indexes in quadriceps strength and each biomechanical variable; alpha was set to .05.

RESULTS

Of the 76 participants, 27 (35%) demonstrated asymmetries in quadriceps strength, defined by quadriceps strength symmetry <90% (n = 23) or >110% (n = 4) (range, 56.9%-131.7%). For the biomechanical variables of interest, 67% demonstrated asymmetry in peak knee flexion angle; 68% and 83% in knee excursion during weight acceptance and midstance, respectively; 74% in internal peak knee extension moment; 57% in medial compartment contact force; and 74% in quadriceps muscle force. There were no significant correlations between quadriceps strength index and limb symmetry indexes for any biomechanical variable after return-to-sport training (P > .129).

CONCLUSION

Among those who completed return-to-sport training after ACLR, subsequent quadriceps strength symmetry was not correlated with the persistent asymmetries in gait biomechanics. After a threshold of quadriceps strength is reached, restoring strength alone may not ameliorate gait asymmetries, and current clinical interventions and return-to-sport training may not adequately target gait.

Gait Analysis and Knee Kinematics in Patients with Anterior Cruciate Ligament Rupture: Before and After Reconstruction

The objective of the study was to evaluate the clinical, functional, and biomechanical symptoms in patients with anterior cruciate ligament (ACL) rupture before and after ACL reconstruction. The study enrolled 20 patients and 20 healthy subjects as controls. Walking biomechanics was assessed at three time points: before surgery and three months and a year or more after surgical reconstruction. Impact loads on both sides differed significantly from the respective values before surgery (p<0.05). Walking cycle duration decreased with time after surgery. On both sides (affected and unaffected), hip movement amplitudes were significantly smaller than in control (p<0.05). They remained so in the follow-up periods after the reconstruction. Before ACL reconstruction, the amplitude of the main flexion of the knee was significantly reduced both on the affected and unaffected sides. The amplitude gradually increased after the reconstruction, and a year post-surgery, it reached, on the operated side, the same values as in the control group. Complete functional recovery of the knee joint was not achieved within a year after the ACL surgical reconstruction. The remaining changes, however, were not clinically pronounced and could only be detected by instrumental gait analysis. The compensatory processes developed bilaterally, in both the hip and knee joints.

Slower Walking Speed Is Related to Early Femoral Trochlear Cartilage Degradation After ACL Reconstruction

Post-traumatic patellofemoral osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR) and early cartilage degradation may be especially common in the femoral trochlear cartilage. Determining the presence of and factors associated with early femoral trochlear cartilage degradation, a precursor to OA, is a critical preliminary step in identifying those at risk for patellofemoral OA development and designing interventions to combat the disease. Early cartilage degradation can be detected using quantitative magnetic resonance imaging measures, such as tissue T₂ relaxation time. The purposes of this study were to (i) compare involved (ACLR) versus uninvolved (contralateral) femoral trochlear cartilage T₂ relaxation times 6 months after ACLR, and (ii) determine the relationship between walking speed and walking mechanics 3 months after ACLR and femoral trochlear cartilage T₂ relaxation times 6 months after ACLR. Twenty-six individuals (age 23 ± 7 years) after primary, unilateral ACLR participated in detailed motion analyses 3.3 ± 0.6 months after ACLR and quantitative magnetic resonance imaging 6.3 ± 0.5 months after ACLR. There were no limb differences in femoral trochlear cartilage T₂ relaxation times. Slower walking speed was related to higher (worse) femoral trochlear cartilage T₂ relaxation times in the involved limb (Pearson's r: -0.583, p = 0.002) and greater interlimb differences in trochlear T₂ relaxation times (Pearson's r: -0.349, p = 0.080). Walking mechanics were weakly related to trochlear T₂ relaxation times. Statement of clinical significance: Slower walking speed was by far the strongest predictor of worse femoral trochlear cartilage health, suggesting slow walking speed may be an early clinical indicator of future patellofemoral OA after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:645-652, 2020.

A novel method for measuring asymmetry in kinematic and kinetic variables: The normalized symmetry index

Gait and movement asymmetries are important variables for assessing locomotor mechanics in humans and other animals and as a predictor of injury risk and success of clinical interventions. The four indices used most often to assess symmetry are not well designed for different variable types, perform poorly when presented with cases of high asymmetry or when variables are of low magnitude, and are easily influenced by small variation in the signal. The purpose of the present study was to test the performance of these indices on previously unpublished data on ACL-R patients and to propose a new index to resolve some of these limitations. The performance of four currently used indices and a new index-the Normalized Symmetry Index (NSI), which is scaled to the range of variables being tested across multiple trials-were compared using force and angular data on participants who had undergone anterior cruciate ligament reconstruction and healthy controls. The NSI performed well compared to all other indices with all variables and had the additional benefit of returning values that range from 0% (full symmetry) to ±100% (full asymmetry). Therefore, the NSI can serve as a universal index for assessing asymmetry in humans, nonhuman animal models, and in a clinical context for assessing risk for injury and clinical outcomes.

Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not

BACKGROUND

Partial meniscectomy dramatically increases the risk for post-traumatic, tibiofemoral osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Concomitant medial meniscus surgery influences walking biomechanics (e.g., medial tibiofemoral joint loading) early after ACLR; whether medial meniscus surgery continues to influence walking biomechanics two years after ACLR is unknown.

RESEARCH QUESTION

Does medial meniscus treatment at the time of ACLR influence walking biomechanics two years after surgery?

METHODS

This is a secondary analysis of prospectively collected data from a clinical trial (NCT01773317). Fifty-six athletes (age 24 ± 8 years) with operative reports, two-year biomechanical analyses, and no second injury prior to two-year testing participated after primary ACLR. Participants were classified by concomitant medial meniscal status: no medial meniscus involvement (n = 36), partial medial meniscectomy (n = 9), and medial meniscus repair (n = 11). Participants underwent biomechanical analyses during over-ground walking including surface electromyography; a validated musculoskeletal model estimated medial compartment tibiofemoral contact forces. Gait variables were analyzed using 3 × 2 ANOVAs with group (medial meniscus treatment) and limb (involved versus uninvolved) comparisons.

RESULTS

There was a main effect of group (p = .039) for peak knee flexion angle (PKFA). Participants after partial medial meniscectomy walked with clinically meaningfully smaller PKFAs in both the involved and uninvolved limbs compared to the no medial meniscus involvement group (group mean difference [95%CI]; involved: -4.9°[-8.7°, -1.0°], p = .015; uninvolved: -3.9°[-7.6°, -0.3°], p = .035) and medial meniscus repair group (involved: -5.2°[-9.9°, -0.6°], p = .029; uninvolved: -4.7°[-9.0°, -0.3°], p = .038). The partial medial meniscectomy group walked with higher involved versus uninvolved limb medial tibiofemoral contact forces (0.45 body weights, 95% CI: -0.01, 0.91 BW, p = 0.053) and truncated sagittal plane knee excursions, which were not present in the other two groups.

SIGNIFICANCE

Aberrant gait biomechanics may concentrate high forces in the antero-medial tibiofemoral cartilage among patients two years after ACLR plus partial medial meniscectomy, perhaps explaining the higher osteoarthritis rates and offering an opportunity for targeted interventions.

LEVEL OF EVIDENCE

Level III.

Gait Mechanics in Women of the ACL-SPORTS Randomized Control Trial: Interlimb Symmetry Improves Over Time Regardless of Treatment Group

Women after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) are more likely than men to exhibit asymmetric movement patterns, which are associated with post-traumatic osteoarthritis. We developed the ACL specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of strength, agility, plyometric, and secondary prevention (SAPP) training with and without perturbation training (SAPP + PERT) on gait mechanics in women after ACLR. We hypothesized that movement symmetry would improve over time across both groups but more so among the SAPP + PERT group. Thirty-nine female athletes 3-9 months after primary ACLR were randomized to SAPP or SAPP + PERT training. Biomechanical testing during overground walking occurred before (Pre-training) and after (Post-training) training and one and 2 years post-operatively. Hip and knee kinematic and kinetic variables were compared using repeated measures analysis of variance with Bonferroni corrections for post hoc comparisons (α = 0.05). There was a time by limb interaction effect (p = 0.028) for peak knee flexion angle (PKFA), the primary outcome which powered the study, characterized by smaller PKFA in the involved compared to uninvolved limbs across treatment groups at Pre-training, Post-training, and 1 year, but not 2 years. Similar findings occurred across sagittal plane knee excursions and kinetics and hip extension excursion at midstance. There were no meaningful interactions involving group. Neither SAPP nor SAPP + PERT training improved walking mechanics, which persisted 1 but not 2 years after ACLR. Statement of clinical significance: Asymmetrical movement patterns persisted long after participants achieved symmetrical strength and functional performance, suggesting more time is needed to recover fully after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1743-1753, 2019.

Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts

Background:

Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential.

Purpose:

(1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo).

Study Design:

Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3.

Methods:

A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes.

Results:

No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores (P < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS–Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON (P = .011).

Conclusion:

Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR.

Registration:

NCT01773317 (ClinicalTrials.gov identifier).

Psychological Readiness to Return to Sport Is Associated With Knee Kinematic Asymmetry During Gait Following Anterior Cruciate Ligament Reconstruction

BACKGROUND

Gait asymmetry is frequently observed following anterior cruciate ligament reconstruction (ACLR). Psychological readiness to return to sport is associated with functional and activity-related outcomes after ACLR. However, the association between gait asymmetry and psychological readiness to return to sport is unknown.

OBJECTIVES

To determine the relationship between kinematic and kinetic measures of knee symmetry during gait and psychological readiness to return to sport following ACLR.

METHODS

In this controlled laboratory, cross-sectional study, 79 athletes (39 women) underwent gait analysis following impairment resolution after ACLR (ie, full range of motion, minimal or no effusion, quadriceps strength index of 80% or greater). Interlimb differences during gait were calculated for sagittal plane knee angles at initial contact, peak knee flexion, and peak knee extension, as well as for peak knee flexion moment and peak knee adduction moment. Athletes completed the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) to assess psychological readiness to return to sport. Pearson correlations were used to examine the association between ACL-RSI score and each gait symmetry variable.

RESULTS

Significant negative correlations were observed between the ACL-RSI and 2 kinematic variables: knee flexion angle at initial contact (r = -0.281, P = .012) and peak knee flexion (r = -0.248, P = .027). In general, lower scores on the ACL-RSI were associated with greater interlimb asymmetry.

CONCLUSION

There was a weak association between psychological readiness to return to sport and knee kinematic asymmetry during gait. J Orthop Sports Phys Ther 2018;48(12):968-973. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8084.

Altered kinematics after anterior cruciate ligament reconstruction, and their role in the prevention of osteoarthritis

Background/Aims:

Anterior cruciate ligament injury is common, and anterior cruciate ligament reconstruction has become the standard of care that aims to restore knee stability, return to activity, and prevent secondary injury.

Methods:

A literature review was carried out using PubMed and Science Direct databases from 1998 through 2017. Search terms included: anterior cruciate ligament reconstruction and knee osteoarthritis; kinematics after anterior cruciate ligament reconstruction; and prevention of knee osteoarthritis. A total of 356 studies matched the search terms. After removing duplicates and any studies that were not relevant, 73 studies remained.

Findings:

Individuals usually have impaired neuromuscular control after reconstruction, and abnormal biomechanical patterns may lead to loading of cartilage areas that are not commonly loaded and that, longitudinally, can lead to osteoarthritis. The knee adduction moment indicates loading of the knee joint and has been associated with the development of osteoarthritis and altered gait mechanics have also been implicated in the increased rate of osteoarthritis after anterior cruciate ligament reconstruction, including differences in tibial rotation during walking. Furthermore, altered ankle joint mechanics may be the result of deviations in ankle joint alignment secondary to the structural changes at the knee. It is clear that abnormal mechanical stimulation may cause dysfunction of articular chondrocytes and breakdown of cartilage extracellular matrix, leading to articular cartilage degradation and chondrocyte death. The affected joint will progress to post-traumatic osteoarthritis.

Conclusions:

The restoration of normal knee anatomy and mechanics, such as returning the joint to normal function, improving muscle strength, functional movement prevention programmes, restoring gait symmetry and weight management are recommended.

Biomechanical Deficits at the Hip in Athletes With ACL Reconstruction Are Ameliorated With Neuromuscular Training

BACKGROUND

The efficacy of a neuromuscular training (NMT) program to ameliorate known hip biomechanical risk factors for athletes with anterior cruciate ligament reconstruction (ACLR) is currently unknown. Purpose/Hypothesis: The purpose was to quantify the effects of an NMT program on hip biomechanics among athletes with ACLR and to compare posttraining hip biomechanics with a control group. The hypotheses were that known hip biomechanical risk factors of anterior cruciate ligament (ACL) injury would be significantly reduced among athletes with ACLR after the NMT program and that posttraining hip biomechanics between the ACLR and control cohorts would not differ.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-eight athletes (n = 18, ACLR; n = 10, uninjured) completed a 12-session NMT program. Biomechanical evaluation of a jump-landing task was done before and after completion of the program. Repeated measures analysis of variance was performed to understand the effect of NMT within the ACLR cohort. Two-way analysis of variance was used to compare both groups. Post hoc testing was done for significant interactions. Hip biomechanical variables at initial contact are reported.

RESULTS

The athletes with ACLR who completed the NMT program had a significant session × limb interaction ( P = .01) for hip external rotation moment and a significant main effect of session for hip flexion angle ( P = .049) and moment ( P < .001). There was a significant change for the involved ( P = .04; 528% increase) and uninvolved ( P = .04; 57% decrease) limbs from pre- to posttraining for hip rotation moment. The ACLR cohort had an increase in hip flexion angle (14% change) and a decrease in hip flexion moment (65% change) from pre- to posttraining. Posttraining comparison for these same hip biomechanical variables of interest revealed no significant interactions ( P > .05) between the ACLR and control cohorts. There was a significant main effect of group ( P = .02) for hip flexion angle, as the ACLR cohort demonstrated greater hip flexion angle than that of the control group.

CONCLUSION

For athletes with ACLR, hip biomechanical measures of ACL injury risk show significant improvements after completion of an NMT program.

CLINICAL RELEVANCE

Athletes with ACLR who are participating in an NMT program may ameliorate known hip biomechanical risk factors for an ACL injury.

Gait mechanics and tibiofemoral loading in men of the ACL-SPORTS randomized control trial

The risk for post-traumatic osteoarthritis is elevated after anterior cruciate ligament reconstruction (ACLR), and may be especially high among individuals with aberrant walking mechanics, such as medial tibiofemoral joint underloading 6 months postoperatively. Rehabilitation training programs have been proposed as one strategy to address aberrant gait mechanics. We developed the anterior cruciate ligament specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of 10 post-operative training sessions consisting of strength, agility, plyometric, and secondary prevention exercises (SAPP) or SAPP plus perturbation (SAPP + PERT) training on gait mechanics after ACLR. A total of 40 male athletes (age 23 ± 7 years) after primary ACLR were randomized to SAPP or SAPP + PERT training and tested at three distinct, post-operative time points: 1) after impairment resolution (Pre-training); 2) following 10 training sessions (Post-training); and 3) 2 years after ACLR. Knee kinematic and kinetic variables as well as muscle and joint contact forces were calculated via inverse dynamics and a validated electromyography-informed musculoskeletal model. There were no significant improvements from Pre-training to Post-training in either intervention group. Smaller peak knee flexion angles, extension moments, extensor muscle forces, medial compartment contact forces, and tibiofemoral contact forces were present across group and time, however the magnitude of interlimb differences were generally smaller and likely not meaningful 2 years postoperatively. Neither SAPP nor SAPP + PERT training appears effective at altering gait mechanics in men in the short-term; however, meaningful gait asymmetries mostly resolved between post-training and 2 years after ACLR regardless of intervention group. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2364-2372, 2018.

Gait Mechanics After ACL Reconstruction Differ According to Medial Meniscal Treatment

BACKGROUND

Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both. Although osteoarthritis development is multifactorial, altered walking mechanics may influence osteoarthritis progression. The purpose of this study was to compare gait mechanics after ACLR among participants who had undergone no medial meniscal surgery, partial medial meniscectomy, or medial meniscal repair.

METHODS

This was a secondary analysis of data collected prospectively as part of a clinical trial. Sixty-one athletes (mean age of 21.4 ± 8.2 years) who had undergone primary ACLR participated in the study when they achieved impairment resolution (5.3 ± 1.7 months postoperatively), including minimal to no effusion, full knee range of motion, and ≥80% quadriceps-strength symmetry. Participants were classified by concomitant medial meniscal treatment: no involvement or nonsurgical management of a small, stable tear; partial meniscectomy; or meniscal repair. Participants underwent comprehensive walking analyses. Joint contact forces were estimated using a previously validated, electromyography-driven musculoskeletal model. Variables were analyzed using a mixed-model analysis of variance with group and limb comparisons (α = 0.05); group comparisons of interlimb differences in measurements (surgical minus contralateral limb) were performed to determine significant interactions.

RESULTS

The participants in the partial meniscectomy group walked with a higher peak knee adduction moment (pKAM) in the surgical versus the contralateral limb as compared with those in the meniscal repair group and those with no medial meniscal surgery (group difference for partial versus repair: 0.10 N-m/kg-m, p = 0.020; and for partial versus none: 0.06 N-m/kg-m, p = 0.037). Participants in the repair group walked with a smaller percentage of medial to total tibiofemoral loading in the surgical limb compared with both of the other groups (group difference for repair versus partial: -12%, p = 0.001; and for repair versus none: -7%, p = 0.011). The participants in the repair group loaded the medial compartment of the surgical versus the contralateral limb 0.5 times body weight less than did the participants in the partial meniscectomy group.

CONCLUSIONS

Participants in the partial meniscectomy group walked with higher pKAM and shifted loading toward the medial compartment of the surgical limb, while participants in the repair group did the opposite, walking with lower pKAM and unloading the surgical limb relative to the contralateral limb. These findings may partially explain the conflicting evidence regarding pKAM after ACLR and the elevated risk for osteoarthritis (whether from overloading or underloading) after ACLR with concomitant medial meniscectomy or repair.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Functional and Patient-Reported Outcomes Improve Over the Course of Rehabilitation: A Secondary Analysis of the ACL-SPORTS Trial

BACKGROUND

The Anterior Cruciate Ligament-Specialized Post-Operative Return to Sports (ACL-SPORTS) randomized controlled trial was designed to address deficits in functional and patient-reported outcomes. The trial examined the effects of a secondary ACL prevention program that included progressive strengthening, agility training, plyometrics (SAP), and other components of current primary prevention protocols, with perturbation training (SAP + PERT group) and without PERT (SAP group). A secondary purpose of this study was to examine whether study outcomes differed between men and women.

HYPOTHESES

(1) Athletes in both the SAP and SAP + PERT groups will have improved knee function and patient-reported outcome measures from pre- to posttraining, (2) the SAP + PERT group would have higher outcome scores than the SAP group, and (3) outcomes will differ by sex.

STUDY DESIGN

Randomized controlled trial (NCT01773317).

LEVEL OF EVIDENCE

Level 2.

METHODS

A total of 79 athletes (39 women) were randomized into the SAP and SAP + PERT groups. All athletes had undergone primary ACL reconstruction and achieved 80% quadriceps strength limb symmetry (QI), full range of motion, had minimal effusion, and had no pain. Additionally, all had begun running again. Prior to and after the training program, athletes' QI, hopping, and patient-reported outcomes were assessed. Repeated-measures analyses of variance were used to determine whether there were differences between groups. Subsequently, the SAP and SAP + PERT groups were collapsed to analyze differences between sexes.

RESULTS

There were significant increases for all variables, with the exception of QI. There were no differences between the SAP and SAP + PERT groups. Both men and women made significant improvements in all knee function and patient-reported outcome measures except QI. Men made significant improvements in QI, whereas women did not.

CONCLUSION

The common elements of the training program that all athletes received (10 sessions of progressive strengthening, agility training, plyometrics, and secondary prevention) may be a beneficial addition to the return-to-sport phase of ACL reconstruction rehabilitation. The results suggest that women may require further quadriceps strengthening to maintain and improve QI, an important focus given the relationship between QI and risk for reinjury.

CLINICAL RELEVANCE

During the return-to-sport phase of ACL reconstruction rehabilitation, clinicians tend to shift their focus away from strengthening toward more advanced sports-related tasks. These results indicate that women in particular need continued focus on quadriceps strengthening.

TWO YEAR ACL REINJURY RATE OF 2.5%: OUTCOMES REPORT OF THE MEN IN A SECONDARY ACL INJURY PREVENTION PROGRAM (ACL-SPORTS)

BACKGROUND

The Anterior Cruciate Ligament-Specialized Post-Operative Return to Sports (ACL-SPORTS) randomized control trial (RCT) examined an evidence-based secondary ACL injury prevention training program, involving progressive strengthening, agility training, and plyometrics. The RCT examined the benefit of the training program with and without a neuromuscular training technique called perturbation training.

HYPOTHESIS/PURPOSE

The purpose of this study was to report the return to sport and second ACL injury incidence outcomes of the men in the ACL-SPORTS trial.

STUDY DESIGN

Secondary analysis of a RCT.

METHODS

Forty cutting and pivoting sport male athletes participated in the ACL-SPORTS trial, return to sport testing, and in follow-up sessions at one and two years after ACL reconstruction. Variables of interest at one and two years were return to sport, return to preinjury level of sport, and second ACL injuries. Mean time to passing return to sport criteria, the number of athletes returning to sport and preinjury level of sport and the incidence proportion of second ACL injuries were calculated.

RESULTS

Athletes passed return to sport criteria 232 ± 99 days after ACLR. One year after ACL reconstruction 95% had returned to sport, 78% at their preinjury level. Two years after ACL reconstruction all athletes had returned to sport, 95% at their preinjury level and only one athlete had a second ACL injury.

CONCLUSIONS

The results of this study indicate that men in the ACL-SPORTS trial had much higher return to sport rates and much lower second ACL injury rates than those reported in the literature.

LEVEL OF EVIDENCE

1b.

Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction

BACKGROUND

Athletes often are cleared to return to activities 6 months after anterior cruciate ligament (ACL) reconstruction; however, knee function measures continue to improve up to 2 years after surgery. Interventions beyond standard care may facilitate successful return to preinjury activities and improve functional outcomes. Perturbation training has been used in nonoperative ACL injury and preoperative ACL reconstruction rehabilitation, but has not been examined in postoperative ACL reconstruction rehabilitation, specifically return to sport rehabilitation.

QUESTIONS/PURPOSES

The purpose of this study was to determine whether there were differences at 1 and 2 years after ACL reconstruction between the male SAP (strengthening, agility, and secondary prevention) and SAP+PERT (SAP protocol with the addition of perturbation training) groups with respect to (1) quadriceps strength and single-legged hop limb symmetry; (2) patient-reported knee outcome scores; (3) the proportion who achieve self-reported normal knee function; and (4) the time from surgery to passing return to sport criteria.

METHODS

Forty men who had completed ACL reconstruction rehabilitation and met enrollment criteria (3-9 months after ACL reconstruction, > 80% quadriceps strength limb symmetry, no pain, full ROM, minimal effusion) were randomized into the SAP or SAP+PERT groups of the Anterior Cruciate Ligament-Specialised Post-Operative Return to Sports trial (ACL-SPORTS), a single-blind randomized clinical study of secondary prevention and return to sport. Quadriceps strength, single-legged hopping, the International Knee Documentation Committee (IKDC) 2000 subjective knee form, Knee Injury and Osteoarthritis Outcome Score (KOOS)-sports and recreation, and KOOS-quality-of-life subscales were collected 1 and 2 years after surgery by investigators blind to group. Athletes were categorized as having normal or abnormal knee function at each time point based on IKDC score, and the time until athletes passed strict return-to-sport criteria was also recorded. T-tests, chi square tests, and analyses of variance were used to identify differences between the treatment groups over time.

RESULTS

There were no differences between groups for quadriceps symmetry (1 year: SAP = 101% ± 14%, SAP+PERT = 101% ± 14%; 2 years: SAP = 103% ± 11%, SAP+PERT = 98% ± 14%; mean differences between groups at 1 year: 0.4 [-9.0 to 9.8], 2 years = 4.5 [-4.3 to 13.1]; mean difference between 1 and 2 years: SAP = -1.0 [-8.6 to 6.6], SAP+PERT = 3.0 [-4.3 to 10.3], p = 0.45) or single-legged hop test limb symmetry. There were no clinically meaningful differences for any patient-reported outcome measures. There was no difference in the proportion of athletes in each group who achieved normal knee function at 1 year (SAP 14 of 19, SAP+PERT 18 of 20, odds ratio 0.31 [0.5-19.0]; p = 0.18); however, the SAP+PERT group had fewer athletes with normal knee function at 2 years (SAP 17 of 17, SAP+PERT 14 of 19, p = 0.03). There were no differences between groups in the time to pass return to sport criteria (SAP = 325 ± 199 days, SAP+PERT = 233 ± 77 days; mean difference 92 [-9 to 192], p = 0.09).

CONCLUSIONS

This randomized trial found few differences between an ACL rehabilitation program consisting of strengthening, agility, and secondary prevention and one consisting of those elements as well as perturbation training. In the absence of clinically meaningful differences between groups in knee function and self-reported outcomes measures, the results indicate that perturbation training may not contribute additional benefit to the strengthening, agility, and secondary prevention base of the ACL-SPORTS training program.

LEVEL OF EVIDENCE

Level II, therapeutic study.