Altered postural sway persists after anterior cruciate ligament reconstruction and return to sport

Relationship between Kinesiophobia and Dynamic Postural Stability after Anterior Cruciate Ligament Reconstruction: A Prospective Cohort Study

Anterior cruciate ligament (ACL) injuries in young, active patients generally require ACL reconstruction (ACLR) to restore mechanical and postural stability. The fear of movement or reinjury (kinesiophobia) has become increasingly recognized in the post-ACLR population; however, the association between restoration of postural stability and kinesiophobia remains largely unknown. The purpose of this study was to investigate changes in mean Tampa Scale of Kinesiophobia-11 (TSK-11), dynamic motion analysis (DMA) scores, and time on the testing platform, as well as any correlation between TSK-11 and mean overall and individual translational and rotational DMA scores during the first 12 months following ACLR. Cohort study. Patients undergoing ACLR were prospectively enrolled and dynamic postural stability and kinesiophobia based on the TSK-11 were collected within 2 days prior to surgery and at 6 and 12 months following ACLR. Dynamic postural stability was quantified by calculating a DMA score, with score calculated in three translational (anterior/posterior [AP], up/down [UD], medial/lateral [ML]) and three rotational (left/right [LR], flexion/extension, and internal/external rotation) independent planes of motions. Correlations between DMA and TSK-11 scores at each time point were analyzed. A total of 25 patients meeting inclusion criteria were analyzed. Mean overall DMA and TSK-11 scores increased with each successive testing interval. At 6-month follow-up, a weakly positive association between TSK-11 and DMA scores was appreciated based on overall DMA, AP, UD, ML, and LR. At 12 months, a moderately positive correlation was appreciated between TSK-11 and the translational, but not rotational, planes of motion. Following ACLR, lower level of kinesiophobia were found to be moderately associated with improved dynamic stability, especially in the translation planes of motion.

Characterizing Longitudinal Alterations in Postural Control Following Lower Limb Injury in Professional Rugby Union Players

Assessment of player's postural control following a lower limb injury is of interest to sports medicine practitioners due to its fundamental role in daily tasks and sporting activities. The aim was to longitudinally monitor professional rugby union players' postural control during each phase of the rehabilitation program (acute, middle, and late) following a lower limb injury. Seven male rugby union players (height 1.80 [0.02] m; mass 100.3 [11.4] kg; age 24 [4] y) sustained a time loss, noncontact lower limb injury. Static postural control was assessed via sway path (in meters), and dynamic postural control was assessed via vertical postural stability index. Group differences (P < .05) were reported across the acute, middle, and late phase. Smaller magnitudes of sway path were observed for eyes-open sway path, and for the middle and late phase smaller magnitudes of vertical postural stability index (P < .05) at the end session compared with first session. Whereas larger magnitudes of vertical postural stability index were found between baseline and the last session (P < .05). Large interindividual and intraindividual variation was apparent across the 3 phases of rehabilitation. Postural control improvements were identified during rehabilitation. However, postural control did not return to baseline, with altered kinetics throughout each rehabilitation phase.

Comparison of postural sway in individuals with and without dynamic knee valgus

BACKGROUND

Dynamic knee valgus (DKV) is a multi-planar faulty movement pattern that can cause faulty postural control. The primary objective of this study is to investigate the differences in postural sway (PS) between individuals aged 18-30 years old diagnosed with and without DKV.

METHODS

In this cross-sectional study, 62 students (39 males and 23 females) with and without DKV (age: 24.58 ± 2.63 years) were selected and assigned to two groups by conducting the single-leg squat test in the screening stage. The Biodex balance system was then employed to compare the two groups in PS. Mann-Whitney U test was conducted to compare the groups in PS (p ≤ 0.05).

RESULTS

The study's findings indicate that individuals with DKV did not exhibit any significant differences, compared to those without, about the anterior-posterior stability index (with p values for both static and dynamic situations at 0.309 and 0.198, respectively), medial-lateral stability index (with p values for both static and dynamic situations at 0.883 and 0.500, respectively), and overall stability index (with p values for both static and dynamic situations at 0.277 and 0.086, respectively).

CONCLUSION

Though several possible factors could contribute to the lack of significant differences in postural sway between individuals with and without DKV, such as measurement tool differences, variable sensitivity in postural stability tests, and differences in movement variability and test stance, we recommend analyzing postural sway in more functional tasks and with different methodological patterns in future studies. Such research could help develop targeted interventions for individuals with DKV and offer a better understanding of the relationship between postural control and DKV.

Changes in Dynamic Postural Stability After ACL Reconstruction: Results Over 2 Years of Follow-up

Background:

The anterior cruciate ligament (ACL) is crucial for knee proprioception and postural stability. While ACL reconstruction (ACLR) and rehabilitation improve postural stability, the timing in improvement of dynamic postural stability after ACLR remains relatively unknown.

Purpose:

To evaluate changes in dynamic postural stability after ACLR out to 24 months postoperatively.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients undergoing ACLR were prospectively enrolled, and dynamic postural stability was assessed within 2 days before surgery, at 3-month intervals postoperatively to 18 months, then at 24 months. Measurements were made on a multidirectional platform tracking the patient’s center of mass based on pelvic motion. The amount of time the patient was able to stay on the platform was recorded, and a dynamic motion analysis score, reflecting the patient’s ability to maintain one’s center of mass, was generated overall and in 6 independent planes of motion.

Results:

A total of 44 patients with a mean age of 19.7 ± 6.2 years completed the study protocol. Overall mean dynamic postural stability improved significantly at 3, 6, 9, and 12 months after surgery, with continued improvement out to 24 months. Notable improvements occurred in medial/lateral and anterior/posterior stability from baseline to 6 months postoperatively, while internal/external rotation and flexion/extension stability declined initially after surgery from baseline to 3 months postoperatively before stabilizing to the end of the study period.

Conclusion:

Overall dynamic postural stability significantly improved up to 12 months after ACLR. Improvement in postural stability occurred primarily in the medial/lateral and anterior/posterior planes of motion, with initial decreases in the flexion/extension and internal/external rotational planes of motion.

An obstacle clearance test for evaluating sensorimotor control after anterior cruciate ligament injury: A kinematic analysis

Sensorimotor deficits, particularly proprioceptive, are often reported following rupture of the anterior cruciate ligament (ACL). High secondary injury rates and long-term negative consequences suggest that these deficits are not properly identified using current assessment methods. We explored a novel obstacle clearance test to evaluate sensorimotor control in individuals following ACL reconstruction (ACLR) and rehabilitation. Thirty-seven post-ACLR individuals, 23 nonathletic asymptomatic controls (CTRL), and 18 elite athletes stepped over a hurdle-shaped obstacle, downward vision occluded, aiming for minimal clearance. Kinematic outcomes (3D motion capture) for the leading and trailing legs, for two unpredictably presented obstacle heights, were categorized into Accuracy: vertical foot clearance and minimal distance from the obstacle; Variability: end-point and hip/knee trajectory; and Symmetry: trunk/hip/knee crossing angles, hip-knee-ankle movement, and velocity curves. Accuracy was worse for CTRL compared with both other groups. ACLR had less leading and trailing vertical foot clearance with their injured compared with their noninjured leg. ACLR and athletes had less crossing knee flexion in their injured/nondominant legs compared with their contralateral leg, both leading and trailing. ACLR showed greater trunk flexion when crossing with their injured leg, both leading and trailing. For the leading leg, ACLR showed greater asymmetry for the hip-knee-ankle velocity curve compared with elite athletes. Trailing leg trajectory variability was lower for ACLR compared with CTRL and athletes for higher obstacles. Clinical significance: Sensorimotor deficits in individuals post-ACLR were reflected by greater asymmetry and less variable (more stereotypical) trajectories rather than limb positioning ability. This consideration should be addressed in clinical evaluations.

Is 12 months enough to reach function after athletes' ACL reconstruction: a prospective longitudinal study

CONTEXT

Anterior Cruciate Ligament (ACL) injury is disabling in several sports because it causes knee instability and functional deficit. Usually, surgical treatments produce the best functional outcomes, however, sometimes they are not always able to fully restore stability and function.

OBJECTIVE

The objective of this study was to evaluate postural balance, muscle strength, and functional performance of young athletes with an ACL injury before and after ACL reconstruction.

DESIGN

This was a longitudinal observational prospective study.

METHOD

74 athletes, 60 men, and 14 women, aged between 16 and 45, divided into two groups: the Group-Lesion of ACL with 34 athletes (24.1 years) and the Group-Control with 40 athletes without ACL lesion (27.7 years old). All volunteers performed posturography, isokinetic dynamometry, and the Hop-Test. The ACL-Group was evaluated before and 12 months after the reconstruction and the control group was evaluated once.

RESULTS

The Postoperative ACL Group presented greater limb symmetry, 0.96 (± 0.12), than the preoperative ACL Group, 0.87 (± 0.17), p < 0.01 in the Hop-Test. In the posturography, the displacement area was smaller in the postoperative ACL Group, 19.85 (± 5.74), compared to the preoperative ACL Group, 24.20 (± 8.97), p < 0.01. In isokinetic dynamometry the torque peak was greater in the postoperative ACL Group, 0.91 (± 0.14), than in the preoperative ACL Group, 0.74 (± 0.15), p < 0.01.

CONCLUSION

The functional outcomes increased in ACL reconstruction athletes after 12 months, but not at the same level as in the Control Group. The result indicates an incomplete functional recovery, adaptive changes in postural control after injury, reconstruction, and return to sport.

Evaluation of the Stability of the Subjects with Anterior Cruciate Injuries Reconstruction

Anterior cruciate ligament (ACL) is the most frequently injured ligament in the knee and is often injured during sport-related activities. ACL injuries influence the abilities of the subjects during standing and walking. Although early surgical intervention is preferred treatment for the majority of knee surgeons, the effect of this approach on postural stability of patients is not fully understood. Therefore, the aim of this study was to determine the difference between stability of ACL-reconstructed subjects before and after surgery. A group of 15 consecutive ACL injured patients participated in this study. Postural stability of the patients was evaluated 1 week before and 6 months after surgery (ACL reconstruction with hamstring autograft). A Kistler force plate was used to evaluate center of pressure (COP) sway during quiet standing. The mean values of the COP parameters were obtained in pre and postsurgery conditions. Paired sample t-test was used to evaluate the difference between the stability parameters of the two conditions. The significant point was set at 0.05. The mean value of path length of COP velocity in mediolateral (ML) direction was 1,485.57 ± 479.42 mm and 2,641.33 ± 996.26 mm before and after surgery, respectively (p-value = 0.01). Although the mean value of COP velocity in anteroposterior and ML directions increased after surgery, the difference was only significant for velocity in ML direction (p-value = 0.049). The results of this study showed that the standing stability of those with ACL reconstruction decreased significantly after ACL reconstruction, which may be due to the effects of the surgery on sensory mechanism of ACL and inability of patients to return to their previous deep sense perception and knee proprioception.

The effects of leg preference and leg dominance on static and dynamic balance performance in highly-trained tennis players

In this study, 90 (51 males, 39 females) tennis players performed single-leg quiet stance and single-leg landing tasks. For the static standing task, center-of pressure (CoP) velocities, amplitudes, frequency and area were calculated. For the landing tasks, time to stabilization as well as dynamic postural stability index were considered. The analysis of differences between the legs was done based on two methods for a priori determination of leg preference, one based on the preference of kicking a ball and one based on the preference for single-leg jumping. An additional analysis was done based on the leg dominance (determined post hoc), based on the observed performance of the tasks. In case of the classification based on kicking a ball, there was a statistically significantly lower CoP anterior-posterior velocity and anterior-posterior amplitude in static balance task (p ≤ 0.017; 0.17 ≤ d ≤ 0.28) for the preferred leg. The CoP frequency was higher in the preferred leg for both directions (p ≤ 0.002; 0.10 ≤ d ≤ 0.22). For the landing task, CoP medial-lateral time to stabilization was statistically significantly shorter for the preferred leg (0.28 ± 0.38 s) compared to the non-preferred leg (0.47 ± 0.60 s) (p = 0.012; d = 0.38). There were no differences between the legs for the landing task. Moreover, there were no differences between the legs when we used the preference based on jumping for either of the tasks (d ≤ 0.14). The differences between legs in terms of observed dominance were larger than the differences based on the preference, which stresses the need for clear distinction of limb preference and limb dominance in research and practice. Regarding the effect of leg preference, small differences in static balance may exist between the legs (when the preference is based on kicking a ball).

Kinetic measurement system use in individuals following anterior cruciate ligament reconstruction: a scoping review of methodological approaches

PURPOSE

Our primary objectives were to (1) describe current approaches for kinetic measurements in individuals following anterior cruciate ligament reconstruction (ACLR) and (2) suggest considerations for methodological reporting. Secondarily, we explored the relationship between kinetic measurement system findings and patient-reported outcome measures (PROMs).

METHODS

We followed the PRISMA extension for scoping reviews and Arksey and O'Malley's 6-stage framework. Seven electronic databases were systematically searched from inception to June 2020. Original research papers reporting parameters measured by kinetic measurement systems in individuals at least 6-months post primary ACLR were included.

RESULTS

In 158 included studies, 7 kinetic measurement systems (force plates, balance platforms, pressure mats, force-measuring treadmills, Wii balance boards, contact mats connected to jump systems, and single-sensor insoles) were identified 4 main movement categories (landing/jumping, standing balance, gait, and other functional tasks). Substantial heterogeneity was noted in the methods used and outcomes assessed; this review highlighted common methodological reporting gaps for essential items related to movement tasks, kinetic system features, justification and operationalization of selected outcome parameters, participant preparation, and testing protocol details. Accordingly, we suggest considerations for methodological reporting in future research. Only 6 studies included PROMs with inconsistency in the reported parameters and/or PROMs.

CONCLUSION

Clear and accurate reporting is vital to facilitate cross-study comparisons and improve the clinical application of kinetic measurement systems after ACLR. Based on the current evidence, we suggest methodological considerations to guide reporting in future research. Future studies are needed to examine potential correlations between kinetic parameters and PROMs.

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

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

Monopodal Postural Stability Assessment by Wireless Inertial Measurement Units Through the Fast Fourier Transform

OBJECTIVES

(1) To describe the fast Fourier transform (FFT) multijoint as monopodal postural stability measurement in well-trained athletes, (2) to compare the within-subject FFT between laterality, joints, and body segments, and (3) to establish the within- and between-subject relationship between joints.

METHODS

Twelve national-level basketball players participated voluntarily in this investigation. The participants performed two 60-second repetitions of a monopodal stability test (1 repetition with each lower limb), separated by 3 minutes of active recovery. All tests were recorded by 4 WIMU PRO™ inertial devices located on the ankle, knee, lumbar spine, and thoracic spine. The main variable was total acceleration, where the FFT was applied.

RESULTS

The higher instability results were found in the ankle and in the nondominant lower limb (dominant = 1.131 [0.122] a.u. (arbitrary units); nondominant = 1.141 [0.172] a.u). In the body segment analysis, the greater percentage of differences (%diff) were shown between lumbar spine and knee in the dominant (%diff = -2.989%; d = 0.87) and nondominant (%diff = -3.243%; d = 0.90) lower limb. Finally, very large between-subjects variability was found in all joints and body segments.

CONCLUSIONS

The described protocol is proposed for monopodal postural stability assessment, being useful to provide information about the stability of joints and the body segment between joints. Besides, a within-subject analysis is recommended, and the FFT calculation will enable a linear analysis of each test.

Quadriceps tendon autograft for anterior cruciate ligament reconstruction is associated with high revision rates: results from the Danish Knee Ligament Registry

PURPOSE

The quadriceps tendon (QT) has recently gained interest as an anterior cruciate ligament reconstruction (ACLR) autograft. There is a paucity of data from large cohort studies on failures and revision rates after ACLR using the QT graft. The purpose of the present study is to use the Danish Knee Ligament Reconstruction Registry (DKRR) to compare revision rates, objective knee stability and subjective clinical outcomes in patients who have undergone ACLR with QT, hamstring tendon (HT), and patellar tendon (PT) as a graft for ACLR. It was hypothesized that QT autografts would result in similar objective knee stability and revision rates as HT and PT autografts.

METHODS

Data on primary ACLRs in the DKRR from 2005 through 2017 were analyzed. Knee injury and Osteoarthritis Outcome Scores (KOOS), Tegner activity scale scores, sagittal knee laxity, pivot-shift tests at 1-year follow-up and revision rates at 2-year follow-up were compared for the three autograft cohorts.

RESULTS

A total of 531 QT, 14,213 HT and 1835 PT ACLR were registered in the DKLR between 2005 and 2017. QT autograft was associated with statistically significant increased laxity (1.8 mm) compared to HT autograft (1.5 mm) (p < 0.001) and more positive pivot shift. There was a significant higher revision rate for QT (4.7%), compared to PT (1.5%) and HT (2.3%) autografts at 2-year follow-up (p < 0.002).

CONCLUSION

Quadriceps tendon autografts for ACLR was associated with higher revision rates than HT and PT grafts. QT graft was also associated with small increased objective knee laxity and more positive pivot shift than HT and PT grafts.

LEVEL OF EVIDENCE

III.

Influence of different jaw positions on dynamic balance using Y-balance test

BACKGROUND

Jaw sensory-motor system has been shown to affect static balance of the body. It would be interesting to know whether it can influence dynamic balance as well. The objective of this study is to examine the influence of different jaw positions on dynamic balance using the Y-balance test.

METHODS

Eighty healthy male participants aged 20-35 years were invited to participate in this study. Dynamic balance was measured by the Y-balance test in three directions (anterior, posteromedial, and posterolateral) for each leg separately in three jaw positions: resting jaw (control), open-jaw, and clenched jaw.

RESULTS

There were no significant differences in reach distances between the different jaw positions except in the posterolateral direction. In comparison with resting jaw position, reach distance was significantly higher in open-jaw position for the right leg and in clenched and open-jaw positions for the left leg in the posterolateral direction.

CONCLUSIONS

Although various studies have shown direct or indirect influence of jaw sensory-motor system on static postural control, results of this study point to limited relation with dynamic postural control among healthy subjects. However, it supports the potential of the jaw sensory-motor system to affect motor control during functional tasks in patients with postural instability or similar disorders.

Gait Classification Using Mahalanobis–Taguchi System for Health Monitoring Systems Following Anterior Cruciate Ligament Reconstruction

In this paper, a gait patterns classification system is proposed, which is based on Mahalanobis–Taguchi System (MTS). The classification of gait patterns is necessary in order to ascertain the rehab outcome among anterior cruciate ligament reconstruction (ACLR) patients. (1) Background: One of the most critical discussion about when ACLR patients should return to work (RTW). The objective was to use Mahalanobis distance (MD) to classify between the gait patterns of the control and ACLR groups, while the Taguchi Method (TM) was employed to choose the useful features. Moreover, MD was also utilised to ascertain whether the ACLR group approaching RTW. The combination of these two methods is called as Mahalanobis-Taguchi System (MTS). (2) Methods: This study compared the gait of 15 control subjects to a group of 10 subjects with laboratory. Later, the data were analysed using MTS. The analysis was based on 11 spatiotemporal parameters. (3) Results: The results showed that gait deviations can be identified successfully, while the ACLR can be classified with higher precision by MTS. The MDs of the healthy group ranged from 0.560 to 1.180, while the MDs of the ACLR group ranged from 2.308 to 1509.811. Out of the 11 spatiotemporal parameters analysed, only eight parameters were considered as useful features. (4) Conclusions: These results indicate that MTS can effectively detect the ACLR recovery progress with reduced number of useful features. MTS enabled doctors or physiotherapists to provide a clinical assessment of their patients with more objective way.

Functional Performance Measures Used for Return-to-Sport Criteria in Youth Following Lower-Extremity Injury

CONTEXT

As sport participation increases globally, so will injury-related risks. The process used to determine return-to-sport following injury is vital to future sport participation and injury prevention. Early specialization along with poor management of sport participation causes an increase in injury risk and potential long-term health consequences for youth athletes.

OBJECTIVES

Previous injury is a common intrinsic risk factor for new injuries. Identifying functional performance deficits, defined by return-to-sport criteria, minimizes these risk factors and provides athletes with guidelines to return safely to sport. The purposes of this clinical commentary and literature review are to provide a summary of current concepts and clinical practices and to identify functional performance measures as clinical assessment tools for return-to-play criteria in the youth population.

EVIDENCE

A literature review was completed using numerous databases, where 154 relevant articles were reviewed and 22 articles were included in this commentary. Of the 22 articles using functional performance measures for return-to-sport criteria, 6 were specific to youth, 12 had mixed populations of adults and youth, and 4 were normative samples for specific youth populations. Acquisition: The gaps in the literature pertaining to functional performance measures in the youth population are addressed, and future research needs for return-to-sport criteria are identified.

EVIDENCE SYNTHESIS

This descriptive literature review identifies 22 articles that meet the search criteria for the youth population discussing the use of clinical functional performance measures in order to identify return-to-sport criteria for lower-extremity injuries.

CONCLUSIONS

Due to the inconsistencies in terminology, definitions, and standardization of clinical assessment tools, it seems necessary to create a comprehensive functional performance test battery for the lower extremity that can be used as return-to-sport criteria.

The effect of targeted exercise on knee-muscle function in patients with persistent hamstring deficiency following ACL reconstruction - study protocol for a randomized controlled trial

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction, using hamstring auto-graft is a common surgical procedure, which often leads to persistent hamstring muscle-strength deficiency and reduced function. The purpose of this randomized controlled trial (RCT) is to investigate the effect of a combined, progressive, strength and neuromuscular exercise intervention on knee muscle strength, functional capacity and hamstring muscle-tendon morphology in ACL-reconstructed patients with persistent hamstring muscle-strength deficiency compared with controls.

METHODS/DESIGN

The study is designed as a multicenter, parallel-group RCT with balanced randomization (1:1) and blinded outcome assessments (level of evidence: II) and will be reported in accordance with the CONSORT Statement. Fifty ACL-reconstructed patients (hamstring auto-graft) with persistent limb-to-limb knee-flexor muscle-strength asymmetry at 12-24 months' post surgery, will be recruited through outpatient clinics and advertisements. Patients will be randomized to a 12-week progressive, strength and neuromuscular exercise group (SNG) with supervised training twice weekly or a control intervention (CON) consisting of a home-based, low-intensity exercise program. Outcome measures include between-group change in maximal isometric knee-flexor strength (primary outcome) and knee-extensor muscle strength, hamstring-to-quadriceps strength ratios of the leg that has been operated on and Knee injury and Osteoarthritis Outcome Score (KOOS) (secondary outcomes). In addition, several explorative outcomes will be investigated: The International Knee Documentation Committee Subjective Knee Form (IKDC), the Tegner Activity Score, rate of force development (RFD) for the knee flexors and extensors, tendon regeneration and potential muscle hypertrophy at graft harvest site evaluated by magnetic resonance imaging (MRI), postural control, kinetic/kinematic gait characteristics and knee-related functional capacity.

DISCUSSION

This RCT is designed to investigate the effect of combined, progressive-resistance and neuromuscular exercises on knee-flexor/extensor strength, in the late rehabilitation phase following ACL reconstruction. Reduced hamstring strength represents a potential risk factor for secondary ACL rupture and accelerated progression of osteoarthritis. If deemed effective, the intervention paradigm introduced in this study may help to improve current treatment strategies in ACL-reconstructed patients.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02939677 (recruiting). Registered on 20 October 2016.

Neuromuscular recovery in ACL reconstruction with Bone-Tendon-Patellar-Bone and Semitendinosus-Gracilis autograft

Objective: Several different types of grafts have been used in ACL rupture. The purpose of the study was to compare the recovery of lower limbs muscle strength and proprioception in athletes, who underwent ACL reconstruction with Bone-Patellar-Tendon-Bone (BPTB) versus semitendinosus and gracilis (HS) autografts. Methods: We enrolled 30 male amateur athletes. Each patient was evaluated by isokinetic test, triaxial accelerometer test and balance test with stabilometric platform. Isokinetic test evaluated quadriceps and hamstrings Peak Torque. Accelerometer test evaluated squat jump test (SJT) and stiffness test (ST). The recording on the balance platform was performed with open and closed eyes and evaluated medio-lateral and anterior-posterior pathways. Results:30 patients were selected (15 in group BPTB and 15 in group HS). In SJT we noticed a statistically significant difference in height of jump in the involved side in favour of Group BPTB (p=0.037) and not significant difference in the other parameters. In the ST, we did not observe significant statistical differences in the parameters of the test. The stabilometric platform data and isokinetic peak torque parameters did not show a significant difference. Discussion: Little high quality researches are available to help determine when patients can safely return to full activity and sport. Included evaluation criteria were a combination of factors regarding knee motion, muscles strength and neuromuscular function. Conclusion: In our study, despite a not full recovery of explosive strength in HS group , the balance and the other parameters after one year are comparable between the two graft. In our findings there isn’t clinical difference between the two grafts. We suggest that the evaluation of explosive strength and proprioception are the priority parameters in neuromuscular recovery after ACL reconstruction. (www.actabiomedica.it)

Neuromuscular recovery in ACL reconstruction with Bone-Tendon-Patellar-Bone and Semitendinosus-Gracilis autograft

OBJECTIVE

Several different types of grafts have been used in ACL rupture. The purpose of the study was to compare the recovery of lower limbs muscle strength and proprioception in athletes, who underwent ACL reconstruction with Bone-Patellar-Tendon-Bone (BPTB) versus semitendinosus and gracilis (HS) autografts.

METHODS

We enrolled 30 male amateur athletes. Each patient was evaluated by isokinetic test, triaxial accelerometer test and balance test with stabilometric platform. Isokinetic test evaluated quadriceps and hamstrings Peak Torque. Accelerometer test evaluated squat jump test (SJT) and stiffness test (ST). The recording on the balance platform was performed with open and closed eyes and evaluated medio-lateral and anterior-posterior pathways.

RESULTS

30 patients were selected (15 in group BPTB and 15 in group HS). In SJT we noticed a statistically significant difference in height of jump in the involved side in favour of Group BPTB (p=0.037) and not significant difference in the other parameters. In the ST, we did not observe significant statistical differences in the parameters of the test. The stabilometric platform data and isokinetic peak torque parameters did not show a significant difference.

DISCUSSION

Little high quality researches are available to help determine when patients can safely return to full activity and sport. Included evaluation criteria were a combination of factors regarding knee motion, muscles strength and neuromuscular function.

CONCLUSION

In our study, despite a not full recovery of explosive strength in HS group , the balance and the other parameters after one year are comparable between the two graft. In our findings there isn't clinical difference between the two grafts. We suggest that the evaluation of explosive strength and proprioception are the priority parameters in neuromuscular recovery after ACL reconstruction.

Assessment of the Postural Stability of Female and Male Athletes

OBJECTIVE

Postural stability is often affected by sport-related injuries and subsequently evaluated during postinjury examinations. Intrinsic factors, however, may also affect postural control. We sought to compare the postural control of female and male athletes as measured simultaneously by (1) the modified balance error scoring system (mBESS) and (2) a video-force plate system.

DESIGN

Cross-sectional study.

SETTING

Sports injury prevention center.

PARTICIPANTS

Pediatric, adolescent, and young adult athletes who performed mBESS during an injury prevention evaluation.

INDEPENDENT VARIABLES

We compared the postural control of female and male athletes. We also accounted for independent variables associated with postural stability, including age, body mass index, and history of ankle injury, concussion, and migraine headache.

MAIN OUTCOME MEASURES

Total errors committed during the mBESS and measurements derived from integrated kinematic and kinetic data obtained by a video-force plate system. Differences between males and females were tested using analysis of covariance.

RESULTS

Participants (n = 409) ranged in age from 10 to 29 years (mean = 14.6 ± 2.8); 60% were female. No significant differences on mBESS were detected between females and males; however, female athletes demonstrated significantly better postural stability on the video-force plate analysis during double-leg (P = 0.03, d = 0.28), single-leg (P < 0.001, d = 0.62), and tandem stances (P < 0.001, d = 0.53) when compared with males.

CONCLUSIONS

Uninjured female athletes demonstrate better postural stability on video-force plate analysis than their uninjured male counterparts. These findings provide an important information assistive to clinicians during interpretation of postinjury balance tests.

Evaluation of postural stability in youth athletes: the relationship between two rating systems

OBJECTIVES

The Balance Error Scoring System (BESS) has been documented as a useful way to evaluate postural control following sport-related concussions sustained by youth athletes. However, limitations have been reported with its use due to the reliance on visual observation as the primary measurement outcome. The primary purpose of this study was to examine the correlation between the modified BESS (mBESS) as rated by a clinician and a simultaneous analysis performed by an integrated video-force plate system. The secondary purpose was to assess if a history of prior concussion affected postural control.

METHODS

A group of healthy youth athletes (n = 398; mean age 13.7 ± 2.4 years) completed the mBESS while simultaneously undergoing an integrated video-force plate evaluation to measure postural stability. Spearman rank-order correlations were used to determine the strength of correlation between the 2 rating systems. In addition, performance on the mBESS between those with and without a history of concussion was compared using univariate ANCOVAs.

RESULTS

A moderately high correlation was found during single-leg stance (ρ = -0.64, p < .001), while a weak correlation was found during tandem stance (ρ = -0.30, p < .001). No postural control differences were found between groups with and without a concussion history.

CONCLUSION

The video-force plate rating system correlates well with the clinician rating during the single-leg stance of the mBESS, but not during double-leg or tandem stances. A history of concussion did not affect mBESS scores.

Single-leg postural stability deficits following anterior cruciate ligament reconstruction in pediatric and adolescent athletes

The objective of this study was to compare the postural stability of pediatric and adolescent athletes without anterior cruciate ligament injury with those who underwent anterior cruciate reconstruction (ACLR). Postural stability ratings derived from a video-force plate system during the three stances of the modified Balance Error Scoring System were collected from pediatric and adolescent athletes who underwent ACLR (N=24; mean 1.2 years after surgery) and from uninjured controls (N=479). The postural control rating was calculated as the mean of the displacement and variance of the torso and center of pressure data, normalized on a scale from 0 to 100. A higher rating indicates greater postural stability. Participants who underwent ACLR showed lower postural stability ratings during single-leg stance compared with uninjured controls (40.0 vs. 48.7; P=0.037). ACLR is associated with deficits in postural stability.

Critical components of neuromuscular training to reduce ACL injury risk in female athletes: meta-regression analysis

OBJECTIVE

The aim of this study was to determine key components in neuromuscular training that optimise ACL injury reduction in female athletes using meta-regression analyses.

DESIGN

Systematic review and meta-regression.

DATA SOURCES

The literature search was performed in PubMed and EBSCO.

ELIGIBILITY CRITERIA

Inclusion criteria for the current analysis were: (1) documented the number of ACL injuries, (2) employed a neuromuscular training intervention that aimed to reduce ACL injuries, (3) had a comparison group, (4) used a prospective control study design and (5) recruited female athletes as participants. Two independent reviewers extracted studies which met the inclusion criteria. Methodological quality of included study and strength of recommendation were evaluated. Number of ACL injuries and participants in control and intervention groups, age of participants, dosage of neuromuscular training, exercise variations within neuromuscular training and status of verbal feedback were extracted.

RESULTS

The meta-regression analyses identified age of participants, dosage of neuromuscular training, exercise variations within neuromuscular training and utilisation of verbal feedback as significant predictors of ACL injury reduction (p=0.01 in fixed-effects model, p=0.03 in random-effects model). Inclusion of 1 of the 4 components in neuromuscular training could reduce ACL injury risk by 17.2-17.7% in female athletes. No significant heterogeneity and publication bias effects were detected. Strength of recommendation was rated as A (recommendation based on consistent and good-quality patient-oriented study evidence).

CONCLUSIONS

Age of participants, dosage of neuromuscular training, exercise variations within neuromuscular training and utilisation of verbal feedback are predictors that influence the optimisation of prophylactic effects of neuromuscular training and the resultant ACL injury reduction in female athletes.

Reference values for the Y Balance Test and the lower extremity functional scale in young healthy adults

[Purpose] This study aimed to establish gender-specific reference values for the Y Balance Test (YBT) and the Arabic version of the Lower Extremity Functional Scale (LEFS-Ar) in healthy young adults in Saudi Arabia, and to examine gender differences in the YBT and LEFS-Ar values. [Subjects and Methods] Healthy young adults (31 females, 30 males) completed the YBT and LEFS-Ar in 1 test session. Descriptive statistical analysis (mean, standard deviation, 95% confidence interval) was used to compute the YBT and LEFS-Ar reference values. Independent t-tests were used to examine gender differences in the YBT and LEFS-Ar values. [Results] Gender-specific reference values were obtained for the right, left, dominant, and non-dominant leg as well as for the average performance of both the legs. males showed greater YBT normalized reach distances than females did in the anterior, posteromedial, and posterolateral directions; furthermore, males showed higher YBT composite scores than females did. However, the LEFS-Ar values did not differ between males and females. [Conclusion] Gender-specific reference values were obtained for the YBT and LEFS-Ar in healthy young adults in Saudi Arabia. males performed better than females did in the YBT. However, no gender differences were noted in LEFS-Ar.

Prospectively identified deficits in sagittal plane hip-ankle coordination in female athletes who sustain a second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport

BACKGROUND

Athletes who return to sport after anterior cruciate ligament reconstruction are at increased risk of future ACL injury. Altered coordination of lower extremity motion may increase this risk. The purpose of this study was to prospectively determine if altered lower extremity coordination patterns exist in athletes who go on to sustain a 2nd anterior cruciate ligament injury.

METHODS

Sixty-one female athletes who were cleared to return to sport after anterior cruciate ligament reconstruction were included. Hip-ankle coordination was assessed prior to return to sport with a dynamic postural coordination task. Within 12 months, 14 patients sustained a 2nd ACL injury. Fourteen matched subjects were selected for comparative analysis. Cross-recurrence quantification analysis characterized hip-ankle coordination patterns. A group × target speed (slow vs. fast) × leg (involved vs. uninvolved) analysis of variance was used to identify differences.

FINDINGS

A main effect of group (P = 0.02) indicated that the single injury group exhibited more stable hip-ankle coordination [166.2 (18.9)] compared to the 2nd injury group [108.4 (10.1)]. A leg × group interaction was also observed (P = .04). The affected leg of the single injury group exhibited more stable coordination [M = 187.1 (23.3)] compared to the affected leg of the 2nd injury group [M = 110.13 (9.8)], P = 0.03.

INTERPRETATION

Hip-ankle coordination was altered in female athletes who sustained a 2nd anterior cruciate ligament injury after return to sport. Failure to coordinate lower extremity movement in the absence of normal knee proprioception may place the knee at risk.

A conceptual framework for a sports knee injury performance profile (SKIPP) and return to activity criteria (RTAC)

Injuries to the knee, including intra-articular fractures, ligamentous ruptures, and meniscal and articular cartilage lesions, are commonplace within sports. Despite advancements in surgical techniques and enhanced rehabilitation, athletes returning to cutting, pivoting, and jumping sports after a knee injury are at greater risk of sustaining a second injury. The clinical utility of objective criteria presents a decision-making challenge to ensure athletes are fully rehabilitated and safe to return to sport. A system centered on specific indicators that can be used to develop a comprehensive profile to monitor rehabilitation progression and to establish return to activity criteria is recommended to clear athletes to begin a progressive and systematic approach to activities and sports. Integration of a sports knee injury performance profile with return to activity criteria can guide clinicians in facilitating an athlete's safe return to sport, prevention of subsequent injury, and life-long knee joint health.

Lumbar manipulation and exercise in the management of anterior knee pain and diminished quadriceps activation following acl reconstruction: a case report

BACKGROUND AND PURPOSE

Quadriceps weakness is a common finding following knee injuries or surgery, and can be associated with significant functional limitations. This weakness or muscle inhibition may be due to central inhibitory mechanisms, rather than local peripheral dysfunction. Lumbopelvic manipulation has been shown to effect efferent muscle output by altering nociceptive processing. The purpose of this report is to describe the physical therapy management of anterior knee pain and chronic quadriceps weakness utilizing side-lying rotational lumbar thrust manipulation and therapeutic exercise for an individual eight months status-post ACL reconstruction.

CASE DESCRIPTION

A 20 year-old male presented to physical therapy eight months following anterior cruciate ligament (ACL) reconstruction of the left knee with primary complaints of residual anterior knee pain and quadriceps weakness. The subject was treated with a multimodal approach using side-lying rotational lumbar thrust manipulation in addition to therapeutic exercise.

OUTCOMES

The subject was seen in physical therapy for eight sessions over eight weeks. Lower Extremity Functional Scale (LEFS) scores improved from 58/80 to 72/80, quadriceps force, measured by hand-held dynamometry (HHD), was improved from 70.6 lbs to 93.5 lbs and the subject was able to return to pain free participation in recreational sports.

DISCUSSION

Therapeutic exercises can facilitate improved quadriceps strength, however, in cases where quadriceps weakness persists and there is concurrent pain, other interventions should be considered. In this case, lower quarter stabilization exercise and lumbar thrust manipulation was associated with improved functional outcomes in a subject with anterior knee pain and quadriceps weakness. Side-lying rotational lumbar thrust manipulation may be a beneficial adjunctive intervention to exercise in subjects with quadriceps weakness.

LEVEL OF EVIDENCE

5, Single case report.