Rehabilitation and Return to Play Following Anterior Cruciate Ligament Reconstruction

The relationship between drop vertical jump action-observation brain activity and kinesiophobia after anterior cruciate ligament reconstruction: A cross-sectional fMRI study

BACKGROUND

Injury and reconstruction of anterior cruciate ligament (ACL) result in central nervous system alteration to control the muscles around the knee joint. Most individuals with ACL reconstruction (ACLR) experience kinesiophobia which can prevent them from returning to activity and is associated with negative outcomes after ACLR. However, it is unknown if kinesiophobia alters brain activity after ACL injury.

OBJECTIVES

To compare brain activity between an ACLR group and matched uninjured controls during an action-observation drop vertical jump (AO-DVJ) paradigm and to explore the association between kinesiophobia and brain activity in the ACLR group.

METHODS

This cross-sectional study enrolled 26 individuals, 13 with ACLR (5 males and 8 females, 20.62 ± 1.93 years, 1.71 ± 0.1 m, 68.42 ± 14.75 kg) and 13 matched uninjured controls (5 males and 8 females, 22.92 ± 3.17 years, 1.74 ± 0.10 m, 70.48 ± 15.38 kg). Individuals were matched on sex and activity level. Participants completed the Tampa Scale of Kinesiophobia-11 (TSK-11) to evaluate the level of movement-related fear. To assay the brain activity associated with a functional movement, the current study employed an action-observation/motor imagery paradigm during functional magnetic resonance imaging (fMRI).

RESULTS

The ACLR group had lower brain activity in the right ventrolateral prefrontal cortex relative to the uninjured control group. Brain activity of the left cerebellum Crus I and Crus II, the right cerebellum lobule IX, amygdala, middle temporal gyrus, and temporal pole were positively correlated with TSK-11 scores in the ACLR group.

CONCLUSION

Brain activity for the AO-DVJ paradigm was different between the ACLR group and uninjured controls. Secondly, in participants with ACLR, there was a positive relationship between TSK-11 scores and activity in brain areas engaged in fear and cognitive processes during the AO-DVJ paradigm.

Is resistance training intensity adequately prescribed to meet the demands of returning to sport following anterior cruciate ligament repair? A systematic review

Objective

To identify, critique and synthesise the research findings that evaluate the use of resistance training (RT) programmes on return to sport outcome measures for people following ACL repair (ACLR).

Design and data sources

This systematic review included a comprehensive search of electronic databases (EBSCO health databases (CINAHL, MEDLINE, SPORTDiscus), Scopus and Pedro) performed in June 2020 and was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Studies were appraised using the Downs and Black checklist.

Eligibility criteria

Randomised and non-randomised controlled trials, longitudinal cohort studies and case series were considered for inclusion where an adequate description of the RT intervention was provided as a part of the study's ACLR rehabilitation protocol. Articles that did not include outcome measures related to return to sport criteria were excluded.

Results

Eleven articles met the inclusion criteria and were subjected to appraisal and data extraction. Study quality ranged from poor to excellent. RT intensity varied considerably among studies (between 5% and >80% of one repetition maximum). Only one identified study specifically investigated the effect of a low-intensity versus high-intensity RT protocol. The majority of studies reported participant outcomes that would not meet commonly used return to sport criteria.

Conclusion

There appears to be considerable variation in the intensity of RT prescribed in research for people following ACLR. Furthermore, in most of the identified studies, RT protocols promoted muscle endurance and hypertrophy without progressing to strength or power-based RT. The findings of this review provide insight into potential factors limiting returning to sport and contributing to reinjury for people following ACLR.

Return-to-Sport Rate and Activity Level Are High Following Arthroscopic All-Inside Meniscal Repair With and Without Concomitant Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To systematically review the literature of return-to-sport outcomes following all-inside meniscus repair and evaluate whether concomitant anterior cruciate ligament reconstruction (ACLR) influenced these outcomes.

METHODS

A systematic review of the MEDLINE, PubMed, Embase, and Cochrane Registry of Systematic Reviews databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers examined all literature pertaining to sport outcomes following all-inside meniscal repair. Studies were included if they had a 12-month minimum follow-up and reported return to sport rate, Tegner, or Knee injury and Osteoarthritis Outcome Score (KOOS) Sport outcomes. Studies with meniscal repair techniques other than the all-inside technique were excluded. Studies were not excluded if they contained patients receiving concomitant ACLR. Study quality was evaluated with the Methodological Index for Nonrandomized Studies.

RESULTS

Nineteen studies comprising 872 patients were included in this investigation. The weighted average patient age was 28.7 (range 14.1-42.1) years, and the weighted average follow-up was 56.0 (range 18.0-155.0) months. The mean Methodological Index for Nonrandomized Studies score was 14.4 ± 3.7. Ten investigations reported both preoperative (range 2.3-3.5) and postoperative (range 4.0-7.3) Tegner outcomes, with scores at final follow-up greater in each of the 10 reporting investigations. KOOS Sport outcomes were examined in 5 investigations, with scores at follow-up ranging from 63.6 to 91. Three studies reported a return to sport rate ranging from 89.6 to 90% at follow-up. Four investigations compared sport-related outcomes between isolated meniscal repair and meniscal repair with concomitant ACLR. Two such studies reported no difference between the 2 cohorts, 1 favored the isolated cohort, and 1 favored the combined cohort.

CONCLUSIONS

This systematic review found a 90% return-to-sport rate and high postoperative activity level following all-inside meniscal repair, as assessed by KOOS Sport and Tegner activity scales. Further, concurrent ACLR did not significantly affect these outcomes.

LEVEL OF EVIDENCE

IV, systematic review of level I-IV studies.

Who Passes Return-to-Sport Tests, and Which Tests Are Most Strongly Associated With Return to Play After Anterior Cruciate Ligament Reconstruction?

Background:

Return-to-sport (RTS) testing after anterior cruciate ligament (ACL) reconstruction (ACLR) surgery has become popular. It has been recommended that such testing should incorporate several domains, or set of tests, but it is unclear which are most associated with a successful RTS.

Purpose:

To determine (1) the proportion of patients who can pass a set of self-report and functional tests at 6 months after ACLR; (2) age, sex, and activity level differences between patients who pass and those who do not; and (3) whether specific types of tests are associated with a return to competitive sport at 12 months.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

This was a prospective longitudinal study of 450 patients who had primary ACLR. At 6 months postoperatively, patients completed 2 self-report measures, the International Knee Documentation Committee (IKDC) subjective knee form and ACL–Return to Sport after Injury (ACL-RSI) scale, and 3 functional measures: single hop and triple crossover hop for distance and isokinetic quadriceps strength. Limb symmetry index scores of ≥90 for functional tests, IKDC scores ≥85, and ACL-RSI scores ≥65 were considered indicators of satisfactory recovery. Proportional statistics and contingency analysis were used to determine associations between age, sex, preinjury sports level, and (1) meeting test thresholds and (2) RTS at 12 months.

Results:

Only 17 (3.8%) patients met all 5 test criteria at 6 months, and 95 (21%) patients did not pass any test. More of the younger patients (<21 years) passed all of the functional tests (P < .01), and more male patients met the IKDC threshold (P = .03). Patients who played level I sports before injury had the same pass rates as those who played level II/III sports. Patients who passed the thresholds for the ACL-RSI and IKDC scales had 4 and 3 times the odds, respectively, of RTS at 12 months (both P < .0001). Meeting the threshold for quadriceps strength or either of the hop tests at 6 months was not associated with RTS.

Conclusion:

At 6 months after ACLR, few patients met all of the thresholds of the common tests used to assess RTS ability, although younger patients had higher rates of passing the functional tests. Self-perceived symptoms/function and psychological readiness were associated with a return at 12 months.

Is There Value and Validity for the Use of Return to Sport Test Batteries After Anterior Cruciate Ligament Injury and Reconstruction?

Is there value and validity for the use of return-to-sport (RTS) test batteries? With regard to RTS testing, there has been marked interest and rapid growth in studies that document RTS criteria after anterior cruciate ligament reconstruction. A set of criteria or "test-battery" is typically used to "clear" the athlete for RTS. Although most RTS testing is done with aim of assessing safety, the same measurements can be as used to determine the amount of functional capacity regained. It is suggested that RTS test batteries incorporate multiple domains of risk factors. If testing "works," patients who pass should have a lower risk of reinjury than patients who fail but nonetheless return to sport. More recent studies have attempted to cover a broad range of risk factors, with as many as 15 to 20 RTS tests. This is possibly due to a lack of clear evidence as to what are the most important risk factors for second injury. As a result, few patients pass these combined criteria. Findings from a meta-analysis showed that there is a low rate of passing RTS testing (23%). The findings from this and a second meta-analyses are quite similar, as both showed there was no effect of passing RTS test batteries on overall subsequent anterior cruciate ligament injury. There was a 7% to 9% reduction in risk difference of graft injuries with passing of RTS; however, there was a 4% to 9% risk difference or 176% to 235% increased risk of a contralateral injury with passing of RTS criteria. There remain several problems with RTS test batteries, which include low rates of meeting thresholds, many athletes return without meeting RTS thresholds, evidence for predictive value is limited, small sample sizes in many studies (only 2 studies >100 patients), and many studies don't document RTS rates. Additional issues include questions as to whether testing should be staged, how to monitor progression of rehabilitation, and should these RTS batteries be tailored to age groups?

A research update on the state of play for return to sport after anterior cruciate ligament reconstruction

Most athletes who undergo anterior cruciate ligament (ACL) reconstruction surgery plan to return to some level of sporting activity. However, rates of return to pre-injury sport are often less than might be expected and many factors influence whether individuals return to sport after this surgery. They include surgical and rehabilitation factors as well as social, psychological and demographic characteristics. The fate of the younger athlete who sustains an ACL injury is a topic that has received recent attention due to accumulating evidence that younger athletes are at considerable risk for not only one, but multiple ACL injuries. Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return. The notion that a set of return to sport criteria can be applied to reduce the risk of further injury has become popular with many different criteria proposed. Another risk of returning to sport following ACL reconstruction is that of sustaining injury to the menisci or articular surfaces, which may in turn increase the risk of developing osteoarthritis. Although there is some evidence that ACL reconstruction reduces the risk of osteoarthritis there is stronger evidence that it does little to protect the knee from long term degeneration. Therefore, it should be recognized that return to sport following ACL reconstruction is associated with a risk of further injury and potential development of osteoarthritis.Level of evidence: V.