Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus

Early versus standard return to play following ACL reconstruction: impact on volume of play and career longevity in 180 professional European soccer players: a retrospective cohort study

BACKGROUND

Patients typically follow a 7-9-month return to play (RTP) protocol following anterior cruciate ligament reconstruction (ACLR); however, much of these data have been based on non-elite athletes. The purpose of this study is to understand whether professional soccer players returning to competition < 6-months following ACLR will have an increased risk of graft failure, play fewer seasons postoperatively, and have lower volume of play compared with those returning > 6 months.

MATERIALS AND METHODS

A total of 180 male professional European soccer players were enrolled and underwent ACLR with a single surgeon between April 2008 and December 2016 and returned to sport < 6 months (early RTP group, n = 92) or > 6 months (standard RTP group, n = 88). Time from intervention to RTP (days), same season returns, total games and average minutes played in return season, seasons played after surgery, and playing status were recorded.

RESULTS

The early RTP group returned to soccer sooner (142.8 ± 21.4 days) than the standard RTP group (276.2 ± 118.9) (p < 0.01), and more players returned the same season as the injury in the early RTP group (n = 55/92, 62.5%) than the standard RTP group (n = 18/88, 20.5%) (p < 0.01). The difference in average minutes per game in the first season back was not statistically significant (early RTP, 56.7 ± 22.3 min; standard RTP 49.9 ± 29.8 min, p = 0.094). The early RTP group had significantly longer careers following ACLR (5.7 ± 2.2 seasons) than the standard RTP group (4.7 ± 2.4 seasons) (p = 0.005). The early RTP group sustained more reruptures (n = 4, 4.4%) than the standard RTP group (n = 1, 1.1%).

CONCLUSIONS

Professional European soccer players returning to competition < 6 months following ACLR did not have poorer outcomes than those who returned > 6 months despite the fact that there were three more failures. However, the early RTP group players were more likely to return during the same season, had longer careers after ACLR, and played a similar number of games and minutes per game, but had more graft failures.

LEVEL OF EVIDENCE

Retrospective cohort study level IV.

TRIAL REGISTRATION

Retrospectively registered according to prot. Professionisti_OSS_22.

The feasibility of conducting a randomized controlled trial that compares immediate versus optional delayed surgical repair for treatment of acute Anterior cruciate ligament injury-results of the IODA pilot trial

BACKGROUND

Standard care for anterior cruciate ligament (ACL) injuries often includes surgical reconstruction of the ACL. However, two randomized controlled trials (RCT) concluded that conservative treatment does not result in inferior clinical outcomes compared to immediate ACL reconstruction. More research is needed to verify these results and to assess whether patient-specific parameters can predict whether a patient would benefit from immediate surgery or conservative treatment. However, before running such an RCT, we performed this pilot study to assess the feasibility of recruiting patients for such an RCT.

METHODS

This is a pragmatic, multicenter, randomized, controlled pilot trial with two parallel groups funded by the Belgian Health Care Knowledge Centre (KCE trials). Patients with an acute ACL injury were recruited from two Belgian hospitals. They were randomized to either conservative treatment (e.g., rehabilitation with optional delayed surgery in case of persistent instability) or immediate surgery (< 12 weeks post-injury). The primary aim of this pilot study was to assess the feasibility of participant recruitment. Furthermore, we evaluated adherence to the protocol and the allocated treatment arm and the feasibility of recruiting a representative sample of ACL patients.

RESULTS

Out of the initial 70 screened patients, 29 were included in the pilot study, 15 were randomized in the conservative treatment group, and 14 were in the surgical treatment group. This yielded a recruitment rate of 41%. However, the investigators could not screen many potential patients due to inadequate referrals within the recruiting hospitals. Seven cross-overs were observed between the treatment arms: 3 patients who were assigned to the conservative treatment group insisted on immediate surgery, while four patients allocated to immediate surgery chose not to undergo surgery. Of the initial 29 patients, 5 dropped out after randomization. The recruited sample confirmed the typically young and physically active sample of ACL patients.

CONCLUSIONS

This pilot study confirmed the challenging recruitment process for an RCT that compares a surgical and a non-surgical treatment option. While encountering substantial recruitment challenges, our pilot study revealed that transitioning to a full-scale RCT is feasible, with some essential modifications. Key adjustments encompassed augmenting the number of participating sites, optimizing patient recruitment processes, and extending the recruitment period. Furthermore, this study showed a high completion rate, affirming the feasibility of the study protocol. However, there was a high cross-over rate (7/29 patients) between treatment arms. This should be avoided when progressing to the full trial. The recruited sample reflects a young and active population, which represents the ACL population well.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04408690) on 25/05/2020.

Use of the Uninvolved Limb as Comparator When Calculating Return to Sports Hop Test Symmetry After ACL Reconstruction

BACKGROUND

Horizontal hop testing is a reliable measure included in test batteries after anterior cruciate ligament (ACL) reconstruction (ACLR). Hop test results are typically expressed as limb symmetry indexes (LSIs) comparing the involved limb with the uninvolved limb. Using the uninvolved limb as a comparative measure has been questioned due to concerns that performance may be reduced in this limb also and may not be a stable comparison across time, leading to a falsely inflated LSI. Here, we report changes in uninvolved limb hop scores over 5 timepoints after ACLR.

HYPOTHESIS

Uninvolved limb hop scores would be similar between preoperative rehabilitation and 2 years after ACLR.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level III.

METHODS

Level I and II athletes were enrolled after isolated ACL injury. Participants completed a preoperative hop testing battery after impairment resolution, preoperative rehabilitation, and 6 months, 1 year, and 2 years after ACLR. Linear mixed-effects models were performed separately for each hop and each limb to characterize change in scores over time. Pairwise comparisons for fixed effects of timepoint and estimated marginal means are reported.

RESULTS

A total of 182 athletes (25.0 ± 8.8 years, 44% female) were enrolled a mean of 54 days from ACL injury. For each hop, the uninvolved limb hop distance was statistically different from the impairment resolution timepoint only to various follow-up timepoints (P ≤ 0.009). If athletes underwent preoperative rehabilitation, uninvolved limb hop distance was stable throughout the duration of rehabilitation until 2 years, apart from timed hop from 6 months to 2 years (P = 0.04).

CONCLUSION

The uninvolved limb is a stable comparison for calculating hop test LSIs as part of return-to-sport decisions.

CLINICAL RELEVANCE

These results increase confidence in using symmetry as an outcome and are important for clinicians lacking preinjury hop testing data.

Performance across the isokinetic velocity spectrum: Interpretation for individuals after anterior cruciate ligament reconstruction

BACKGROUND

Quadriceps strength recovery is a focal point of rehabilitation after anterior cruciate ligament reconstruction. Quadriceps function at slow, moderate and faster isokinetic speeds may prove useful to identify individuals with abnormal muscular force-velocity properties. This study's purpose was to investigate changes in quadriceps peak torque and total work across the isokinetic velocity spectrum and assess between the reconstructed limb, uninvolved limb and a control group limb.

METHODS

20 participants after primary anterior cruciate ligament reconstruction and 20 control participants performed 5 repetitions of maximal effort knee extension and flexion at 20°/s, 60°/s, 120°/s, 240°/s, 400°/s. Data were averaged across the middle 3 repetitions at each isokinetic velocity and two-way repeated measures analysis of variance models were conducted to evaluate differences among the limbs. Post-hoc polynomial trend analyses and limb differences at each velocity were evaluated using Bonferroni adjusted contrasts.

FINDINGS

The involved limb demonstrated lower peak torque and total work at all isokinetic velocities compared to the uninvolved and control limbs. There were no differences between the uninvolved limb and control group limb at any velocity. Trend analyses revealed the involved limb decreased at a significantly different rate across the isokinetic velocity spectrum, compared to the uninvolved and control limbs, for peak torque and total work.

INTERPRETATION

Individuals 4 months after anterior cruciate ligament reconstruction demonstrate maximal and sustained quadriceps strength deficits compared to their uninvolved limb and control individuals. The convergence of peak torque and total work across the isokinetic velocity spectrum indicates that slower isokinetic velocities are more discriminative than faster isokinetic velocities for quadriceps testing.

Quality of Movement for Athletes 6 Months After ACL Reconstruction

Background

Anterior cruciate ligament (ACL) injury prevention programs address quality of movement to identify and correct high-risk movement patterns. However, return-to-play decisions after ACL reconstruction (ACLR) are often based on non-sport related quantitative measures such as isokinetic tests, jump testing, and/or time from surgery, with 6 to 9 months a common expectation for progressing to sport-specific training and return to play.

Purpose

To identify the presence in each limb of movement patterns associated with ACL injury in athletes 6 months post-ACLR using a quality-of-movement assessment.

Study Design

Cross-sectional study; Level of evidence: 3.

Methods

A quality-of-movement assessment including 10 dynamic tasks progressing from double- to single-limb and vertical to horizontal movements was administered to 148 athletes at 6 months after ACLR. Tasks were viewed live from the frontal and sagittal planes by a physical therapist and certified strength and conditioning specialist. Movements were evaluated for strategy, depth, alignment, symmetry, and control. The proportion of patients exhibiting faulty movement patterns for each task was assessed in the involved and uninvolved leg and between sex, meniscal injury status, and age. To examine the differences in age, patients were divided into age groups based on their age at the time of surgery (<14 years, 14-18, 19-25, 26-34, and ≥35 years).

Results

Mean time of testing was 6.4 months after ACLR. All patients exhibited faulty movement patterns for ≥1 task on the involved leg. On the involved leg, the proportion of patients demonstrating faulty movement patterns for a task ranged from 52% to 95%. Forward stepdown (P < .001), single-leg squat (P = .03), side-to-side jump (P = .03), and hop to opposite (P = .04) demonstrated higher frequency of faulty movement patterns in the involved versus the uninvolved leg. Rates of faulty movement patterns were not different between sex or meniscal injury status. Single-leg stance on the involved leg (P = .05) and single-leg bridge (uninvolved leg) (P = .02) differed between age groups.

Conclusion

Athletes demonstrated multiple faulty movement patterns that have been associated with both initial and second noncontact ACL injury. Faulty movement patterns were evident in tasks as simple as single-leg stance. The rates of faulty movement were similar in both male and female patients, as well as in the involved and uninvolved limb.

Optimizing return-to-work decisions following anterior cruciate ligament reconstruction: A 12-week evaluation of objective functional assessment and rehabilitation outcomes in patients with occupational injuries

BACKGROUND

Anterior cruciate ligament (ACL) injuries are common, yet there is a critical knowledge gap regarding rehabilitation in non-athlete occupational populations. This lack of research translates to insufficient objective criteria to guide effective clinical decision-making in these patients. This research aimed to assess the impact of a 12-week rehabilitation program with specialized tools on the recovery and return-to-work potential of patients with occupational ACL injuries.

METHODS

A prospective, observational single-center study evaluated rehabilitation outcomes in patients after ACL reconstruction. Twenty patients undergoing ACL reconstruction participated in a 12-week clinical-functional follow-up program. Rehabilitation treatment was assessed through biomechanical gait analysis (dynamometric platform and NedAMH/IBV® software), isokinetic dynamometry ((Biodex 3™), and the Lysholm scale to assess patient-reported function. Statistical analysis included normality testing (Kolmogorov-Smirnov and Shapiro-Wilk tests) and appropriate tests for parametric (one-way ANOVA with repeated measures) or non-parametric data (Friedman test with Wilcoxon signed-rank post-hoc tests).

FINDINGS

Rehabilitation improved gait mechanics (reduced stance time, improved ground reaction forces by the ninth week) and muscle strength (decreased deficit, improved peak torque by 8th-12th week) as measured by biomechanical analysis and isokinetic dynamometry. Patient-reported function (Lysholm scale) also showed significant improvements from the sixth week onwards.

INTERPRETATION

Our findings indicate that rehabilitation following ACL reconstruction significantly enhances patient function in work-related injuries, as demonstrated by improvements in gait, strength, and self-reported outcomes. These objective assessments play a significant role in facilitating safe return-to-work decisions. Further research is necessary to explore job-specific rehabilitation strategies.

Validity of the Uninjured Limb as a Control for Preoperative Assessment in Anterior Cruciate Ligament Reconstruction

Monitoring muscle atrophy in patients undergoing anterolateral cruciate ligament reconstruction is pivotal for optimizing postoperative recovery. Conventionally, the uninjured contralateral limb serves as the control. However, its relevance in patients with prolonged physical activity hiatus due to knee instability remains uncertain. Our objectives were to compare limbs within a control group by assessing combined force measurements, cross-sectional areas (CSAs), and neuromuscular activation. In addition, we compared the contralateral limb of the surgery group preoperatively to the control group. This prospective controlled study (evidence level 2) included 40 healthy subjects (HG) and 30 patients scheduled for ACL surgery (SG). Both groups underwent identical assessments. The two HG limbs were compared to establish the standard difference for all assessed variables, whereas SG contralateral limb was compared with the mean of the control limbs. For HG, the comparisons between limbs showed no significant differences in muscle strength, CSA area, or electromyographic parameters. Similarly, comparisons between the SG contralateral limb and the mean of HG limbs revealed no significant differences in isometric and dynamic strength for the quadriceps and hamstrings (2.5 ± 0.5 and 2.6 ± 0.9 N.m/kg, and 1.7 ± 0.3 and 1.7 ± 0.4 N.m/kg, respectively). Neuromuscular activation and fatigue patterns were also comparable between groups. CSAs discrepancies were attributed to differences in body mass index between groups. These findings indicate that the contralateral limb in ACL_injured patients is functionally similar to that of healthy controls, supporting its use as a valid reference for monitoring postoperative recovery. Trial Registration: NCT03200678.

A Guideline for Validated Return-to-Sport Testing in Everyday Clinical Practice: A Focused Review on the Validity, Reliability, and Feasibility of Tests Estimating the Risk of Reinjury After ACL Reconstruction

Background

Information derived from functional return-to-sport (RTS) tests after primary anterior cruciate ligament (ACL) reconstruction (ACLR) can have a significant impact on the risk reduction of ACL reruptures. However, due to space, time, and financial limitations, few clinicians utilize objective data to assess their patients' functional abilities after ACLR.

Purpose

To identify validated and feasible RTS tests that could reliably estimate the risk of reinjury after ACLR in everyday clinical practice beyond the highly sophisticated laboratory setting.

Study Design

Systematic review; Level of evidence, 4.

Methods

A focused review was performed by experts of the committees for Ligament Injuries and Prevention/Rehabilitation of the German Knee Society. RTS functional tests, their reinjury prognostic values (if known), their reliabilities, and their implementation capacities were extracted from the original studies on the described RTS test setup, as well as from studies on potential test alternatives. These alternatives were required to be less resource-consuming yet still validated and thus able to be implemented into everyday practice. All tests were categorized according to their relevant target objective: isokinetic or isometric strength, functional (hopping and jumping) ability, or self-reported readiness.

Results

In the final analysis, 19 studies involving 7513 patients were included. From these, a total of 21 RTS tests were retrieved, and 13 tests were included. For strength testing, 2 dynamic tests and 1 static test were found to be eligible. Functional ability was represented by 8 different jump, hop, and agility tests. Tests for self-reported readiness included the ACL-Return to Sport after Injury scale and the Knee injury and Osteoarthritis Outcome Score Sport and Recreation subscore. Alternative tests included the 8-repetition maximum test, handheld/portable dynamometer, single-leg vertical (countermovement) hop with inertial sensor or smartphone app, and the drop jump with knee displacement or normalized knee distance measurement.

Conclusion

For most of the strength and functional abilities assessed by RTS tests, validated and less resource-consuming alternatives do exist. Therapists and clinicians working in nonlaboratory settings may find it helpful to select from a menu of established RTS tests and test alternatives for each relevant target objective, depending on their individual requirements.

Prehabilitation prior to anterior cruciate ligament reconstruction is a safe and effective intervention for short- to long-term benefits: A systematic review

PURPOSE

Comprehensively explore current practices in preoperative rehabilitation (prehabilitation) for anterior cruciate ligament reconstruction (ACLR) and assess corresponding clinical outcomes and complication rates.

METHODS

A systematic search of EMBASE, MEDLINE, Cochrane and PubMed was conducted from inception to 1 November 2024. All studies reporting outcomes and/or complications following prehabilitation and ACLR were included. Screening and data abstraction were designed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Revised Assessment of Multiple Systematic Reviews guidelines.

RESULTS

Thirty-six studies with 2326 patients undergoing prehabilitation and ACLR were included. Weighted averages of all clinical outcomes met or surpassed patient acceptable symptom state (PASS) thresholds and return to sports (RTS) criteria. There were no preoperative complications following prehabilitation. Major post-operative complications included graft failure (4.6%), contralateral ACL rupture (1.0%), surgical site infection (0.6%), deep infection (0.4%), non-ACL ligament injury (0.5%), reoperation for hardware removal (0.3%), muscle rupture (0.1%), patellar subluxation (0.1%) and patellar rupture (0.1%).

CONCLUSION

Current prehabilitation practices for ACLR emphasize impairment resolution, ROM restoration, and neuromuscular exercises. Safety of current practices is supported by the absence of preoperative complications and similar post-operative complication rates compared to patients undergoing standard care. Clinical outcomes of patients undergoing prehabilitation were shown to meet and surpass PASS thresholds and RTS criteria, expedite post-operative recovery, and maintain functional improvements up to 10 years post-operation, suggesting that prehabilitation is a safe and effective intervention yielding short- to long-term benefits. There is a need for further high-quality randomized controlled trials and large prospective cohort studies comparing the effect of prehabilitation on post-operative outcomes, reporting specific exercise details and protocol progression.

LEVEL OF EVIDENCE

Level II.

Velocity-based training in mid- and late-stage rehabilitation after anterior cruciate ligament reconstruction: a narrative review and practical guidelines

Resistance training is critical for strength development and physical recovery after anterior cruciate ligament reconstruction (ACLR). Traditional percentage-based training (PBT) methods, which often focus on maximal strength and training to failure, are not able to objectify rapid force development. Velocity-based training (VBT), using movement velocity as a metric for training intensity, offers a promising alternative. This article promotes the use of VBT in ACLR rehabilitation, emphasising its potential to enhance neuromuscular recovery and return-to-sport outcomes. A narrative review of current literature focuses on mid- and late-stage rehabilitation to examine how VBT can address PBT limitations and improve functional recovery and sports performance. VBT provides several advantages, including real-time feedback, individualised load adjustments and better alignment with daily physiological variations. It facilitates the accurate training load prescriptions, enhances motivation and reduces unnecessary fatigue. Monitoring load-velocity profiles and velocity-loss thresholds enables more effective strength and hypertrophy adaptations without reaching muscular failure. In midstage rehabilitation, VBT not only helps to restore muscle strength and hypertrophy using submaximal loads and individualised velocity profiles but also addresses unwanted neuroplasticity following ACLR by providing augmented feedback and facilitating an external focus. In late-stage rehabilitation, VBT focuses on improving explosive strength and power, crucial for sports performance. Despite its benefits, VBT application in rehabilitation is limited by a lack of data on injured populations and specific exercises, such as open-chain single-joint movements. Integrating VBT allows practitioners to enhance traditional rehabilitation protocols, potentially leading to better clinical outcomes and providing a more personalised rehabilitation process.

The role of resistance exercise-induced local metabolic stress in mediating systemic health and functional adaptations: could condensed training volume unlock greater benefits beyond time efficiency?

The majority of "specialised" exercise configurations (e.g., supersets, drop sets, blood flow restriction) are being assessed as "shortcuts" to hypertrophy and strength improvements. However, these advanced training techniques may also offer significant benefits for systemic health and functional outcomes across recreational and clinical populations via locally induced metabolic responses. Stress-regulating mechanisms are known to enhance the body's resilience by facilitating allostasis, the process of coordinating adaptive processes in reaction to stressors such as physical training. Yet, the role of the local metabolic stress provoked by resistance exercise has not gained much research attention despite its wide potential. Positive effects are not only linked to improved muscular endurance, hypertrophy and strength via primary and secondary mechanisms, but also to the release of myokines, hormones, microRNAs, immune factors, inflammatory substances and other endocrine molecules that initiate numerous health-promoting modifications on a systemic level. Resistance exercise strategies that maximise the local accumulation of metabolites are not well defined, although high volume, close proximity to failure and shorter rests seem to be a necessity. Additionally, blood flow restriction training provides a potent alternative for inducing local acidosis, thereby triggering several pathways associated with improved immunity and physical function even in remote muscle tissues. Future research is warranted to further explore advanced resistance training techniques, as these approaches may offer comparable benefits for physical and mental health to those seen with other forms of exercise such as high-intensity interval training and heavy resistance training.

Disparity in anterior cruciate ligament injury management: a case series review across six National Health Service trusts

BACKGROUND

Effective management of anterior cruciate ligament (ACL) injuries requires a comprehensive approach, from initial assessment, through treatment, rehabilitation, and discharge, however no gold standard care pathway exists to help guide clinicians. This case series provides an overview of current ACL injury management processes in six National Health Service (NHS) Trusts.

METHODS

This study utilised a retrospective case series design within six NHS Trusts in the Yorkshire region of the United Kingdom. Using a standard operating procedure, each Trust selected ten consecutive ACL injured patients (≥ 16 years), managed either surgically or non-surgically. Data relating to the patient injury journey, patient and injury characteristics, key pathway events, rehabilitation management, outcome measures, and discharge, were collected. Data was anonymised and analysed using descriptive statistics.

RESULTS

Reviews covered 55 patients, median age 25.5 years, (41 males, 14 females). Median time to specialist assessment from injury was 12 days (Interquartile Range [IQR] 6 to 20 days), with 43 patients managed operatively, and 12 non operatively. The median number of physiotherapy sessions was 21 (IQR 9 to 29.5), with outcome measures being variably used across Trusts. Trusts using patient reported outcome measures (PROMS) consistently with their patients provided more physiotherapy appointments (34.5 and 27) and achieved higher return to sport (RTS) rates. Time from injury to discharge varied with a median of 421 (IQR 249 to 546) days. Discharge criteria were applied inconsistently across Trusts, with 31% of cases not using specific criteria. However, Trusts using standardised discharge criteria showed better RTS outcomes, with 27 (61%) patients successfully returning to sport.

CONCLUSIONS

This case series review highlighted some good practice in initial ACL management across six NHS Trusts in the Yorkshire region. However, from time to MRI diagnosis to discharge, substantial variation in care is observed. Whether treated operatively or non-operatively, for patients aiming to RTS, this was achieved with greater consistency when more physiotherapy appointments were undertaken, outcome measures and PROMs were used, and specific discharge criteria was utilised. Future larger pathway investigation studies incorporating causative and predictive analysis studies on a national scale are required to determine whether similar trends are observed in a wider ACL injured population, which could help to improve national pathways for patients and clinicians working towards ensuring more positive and standardised patient-related ACL injury outcomes.

Criteria-Based Decision Making for Introducing Open Kinetic Chain Exercise after-ACL Reconstruction: A Scoping Review

BACKGROUND

After an anterior cruciate ligament reconstruction (ACLR), mounting evidence suggests that open kinetic chain (OKC) strengthening is safe, reduces the risk of anterior knee pain, and significantly improves the quadriceps strength. However, clinicians are reluctant to use OKC knee strengthening exercises mainly due to the strong beliefs that they might increase graft laxity. The objective of this scoping review is to identify the key criteria employed in the scientific literature for the safe introduction of OKC quadriceps strengthening following ACLR.

METHODS

A scoping review of the literature was conducted on the online databases MEDLINE (PubMed), ScienceDirect, Embase and CINAHL Library online. Data regarding time-based criteria and/or clinical based criteria allowing OKC exercises introduction following ACLR were searched for. Only studies involving patients who performed quadriceps strengthening using any type of OKC exercises were included, regardless of the type, resistance location, load magnitude, type of muscle contraction, knee range of motion, or duration of the strengthening protocol.

RESULTS

Twenty-six studies met the inclusion criteria. Twenty-one employed time-based criteria for the introduction of OKC exercise. The median time from when OKC was permitted was 15 postoperative days (range 1-270 days), while the mean time was 31.6 ± 56.7 postoperative days. In 30.7% of the studies additional clinical examination components were used. These components included range of motion (0-100°), numeric pain scale score < 2 or 3, absence of joint effusion (assess by the stroke test), full knee active extension (assess by the straight leg raise), and walking without crutches for the decision-making regarding OKC exercise introduction.

CONCLUSION

Less than one study in 3 reported clinical criteria for the introduction of OKC exercise. This highlights the absence of consensus among surgeons and physiotherapists, thereby hindering their ability to make informed decisions based on scientific evidence. Although the use of OKC exercise appears to be safe, precautions to maintain the integrity of the surgical repair need to be implemented. The establishment of valid criteria is crucial to support evidence-based decision-making.

Rethinking the Assessment of Arthrogenic Muscle Inhibition After ACL Reconstruction: Implications for Return-to-Sport Decision-Making-A Narrative Review

Arthrogenic muscle inhibition (AMI) is a neuromuscular impairment commonly observed following anterior cruciate ligament reconstruction (ACLR). This condition, characterized by persistent quadricep inhibition due to altered afferent feedback, significantly impacts neuromuscular recovery, delaying return to running and sport. Despite advancements in rehabilitation strategies, AMI may persist for months or even years after ACLR, leading to muscle strength asymmetries, altered biomechanics, and an increased risk of reinjury. The mechanisms underlying AMI involve both peripheral (joint effusion, mechanoreceptor dysfunction) and central (corticospinal inhibition, neuroplasticity alterations) components, which collectively hinder voluntary muscle activation and movement control. AMI alters gait mechanics, reduces knee stability, and promotes compensatory patterns that increase injury risk. Current return-to-sport protocols emphasize strength symmetry and functional performance but often neglect neuromuscular deficits. A comprehensive assessment integrating neuromuscular, biomechanical, and proprioceptive evaluations is needed at specific stages to optimize rehabilitation and minimize reinjury risk. Future research should explore targeted interventions such as neuromuscular stimulation, cognitive-motor training, and advanced gait analysis to mitigate AMI's impact and facilitate a safer, more effective return to sport.

Thessaly Graft Index: An Artificial Intelligence-Based Index for the Assessment of Graft Integrity in ACL-Reconstructed Knees

BACKGROUND

Magnetic resonance imaging (MRI) has proven to be a valuable noninvasive tool to evaluate graft integrity after anterior cruciate ligament (ACL) reconstruction. However, MRI protocols and interpretation methodologies are quite diverse, preventing comparisons of signal intensity across subsequent scans and independent investigations. The purpose of this study was to create an artificial intelligence (AI)-based index (Thessaly Graft Index [TGI]) for the evaluation of graft integrity following ACL reconstruction.

METHODS

The cohort study included 24 patients with an isolated ACL injury that had been treated with a hamstring tendon autograft and followed for 1 year. MRI was performed preoperatively and 1 year postoperatively. The clinical and functional evaluations were performed with use of the KT-1000 and with the following patient-reported outcome measures (PROMs): the Knee Injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Subjective Knee Function form (IKDC), the Lysholm score, and the Tegner Activity Scale (TAS). An AI model, based on the YOLOv5 Nano version, was designed to compute the probability of accurately detecting, in the sagittal plane, a healthy ACL (on a percentage scale) and was trained on healthy and injured knees from the KneeMRI dataset. The model was used to assess the integrity of ACL grafts, with a maximum score of 100. The results were compared with the MRI assessment from an independent radiologist and were correlated with PROMs and KT-1000 laxity.

RESULTS

The mean preoperative and postoperative TGI scores were 64.21 ± 8.96 and 82.37 ± 3.53, respectively. A mean increase of 15% in the TGI scores was observed between preoperative and postoperative images. The minimum threshold for TGI to categorize a graft as healthy on the postoperative MRI was 79.21%. Twenty-two grafts were characterized as intact and 2 as reruptured, with postoperative TGI scores of 71% and 42%. The radiologist's assessment was in total agreement with the TGI scores. The correlation of the TGI ranged from moderate to good with the TAS (0.668), IKDC (0.516), Lysholm (0.521), KOOS total (0.594), and KT-1000 (0.561).

CONCLUSIONS

The TGI is an AI tool that is able to accurately recognize an ACL graft rupture. Moreover, the TGI correlated with the KT-1000 postoperative values and PROM scores.

LEVEL OF EVIDENCE

Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Return to sport after anterior cruciate ligament reconstruction - prognostic factors and prognostic models: A systematic review

BACKGROUND

A variety of criteria are used to make return to sport decisions after anterior cruciate ligament (ACL) reconstruction.

OBJECTIVES

This systematic review summarized and evaluated prognostic factors and clinical prognostic models for returning to sports after ACL reconstruction.

METHODS

Independent pairs of reviewers assessed eligibility, extracted data, and evaluated risk of bias and certainty of evidence. A systematic literature search was conducted in key electronic databases.

INCLUSION CRITERIA

studies published in English, longitudinal cohort or case-control design, reporting outcomes on return to sport or Tegner Activity Score (TAS), participants aged ≥16 years undergoing primary ACL reconstruction, and defined as athletes/sport players or having a pre-injury TAS ≥5. Only associations between predictors and outcomes that were analyzed in ≥3 studies and had consistent results in the same direction in ≥75 % of the studies were considered and reported. Risk of bias was evaluated using the QUIPS or PROBAST tools, and certainty of evidence was evaluated using the GRADE framework.

RESULTS

37 studies (5 low, 6 moderate, and 26 high risk of bias) on prognostic factors and 1 study on prognostic models (low risk of bias), representing 6278 participants, were included. Six prognostic factors were identified and rated as very low certainty evidence: fewer concomitant meniscal injuries, shorter time between injury and surgery, higher jump test scores, better physical functioning, higher muscle strength, and greater psychological readiness to return to sport. Two prognostic models with AUC 0.77-0.78 and 70 % accuracy for predicting return to sport were identified.

CONCLUSION

There is a very low certainty of evidence that returning to sport is associated with both physical, psychological and demographic prognostic factors. More methodologically sound research on prognostic factors and prognostic models for return to sport in athletes after ACL reconstruction is needed.

Effects of preoperative treatment on healthcare utilization and return to work for anterior cruciate ligament injuries: a real-world study using the French healthcare database

OBJECTIVE

To compare healthcare use and the number of days of sickness benefits between people with anterior cruciate ligament (ACL) injury who received physiotherapy before and after ACL reconstruction (ACLR) and those who received physiotherapy after ACLR only. Secondary aim: to measure the association between the volume of preoperative healthcare and post-ACLR recovery.

METHODS

Each individual's care pathway was extracted from a section of the French National Health Data System (SNDS) database (province: Pays de La Loire). The database was queried for the codes related to sickness benefits and healthcare utilization, including physiotherapy, medical and paramedical visits and procedures, medication, and medical equipment provided up to six months before and eighteen months after the ACLR. (Registry/number: ClinicalTrials.gov/NCT05737719).

RESULTS

Based on the timing of physiotherapy, two subcohorts were created from the database: 'prehabilitation' (n = 513) for those receiving physiotherapy before and after ACLR; 'no prehabilitation' (n = 630) for those only receiving physiotherapy after ACLR. Before ACLR, healthcare use was higher for the 'prehabilitation' group, including the number of medical visits (3.9 ± 2.3 vs. 3.0 ± 1.9 univariate p < 0.001), analgesia (mild opioids 60.4% vs. 49.8% univariate p < 0.001), dispensing of medical equipment (85.0% vs. 68.9% univariate p < 0.001) and sickness benefit days (52.7 ± 45.6 days vs. 33.2 ± 35.8 days, univariate p < 0.001). After ACLR, the 'prehabilitation' group underwent a higher number of physiotherapy sessions (46.8 ± 21.9 sessions vs 35.8 ± 19.0 sessions, p < 0.001) but had a similar number of sickness benefit days (94.7 ± 77.8 days vs 87.1 ± 69.9 days, p = 0.092). From the multivariate analysis (n = 1143): age, comorbidities, the preoperative number of sickness benefit days, and the number of physiotherapy sessions before ACLR explained 24% of the variance in days of sickness benefits after ACLR.

CONCLUSION

Prehabilitation was associated with higher healthcare utilization before and after ACLR. Prehabilitation, and other preoperative variables, explained only a part of the number of days of sickness benefits after ACLR.

Serial Changes in Muscle Strength and Dynamic Balance After Lateral Meniscal Allograft Transplantation: A Retrospective Cohort Study of 55 Patients

BACKGROUND

Despite numerous studies examining subjective clinical scores after meniscal allograft transplantation (MAT), research focusing specifically on functional measures is lacking.

PURPOSE

To evaluate the serial changes in isokinetic muscle strength and dynamic balance during the first postoperative year after lateral MAT (LMAT).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 55 patients who underwent LMAT underwent subjective functional assessment using the Lysholm and subjective International Knee Documentation Committee (IKDC) scores. The objective functions, evaluated using isokinetic muscle strength testing and the Y-balance test for dynamic postural stability, were recorded preoperatively and 6 and 12 months postoperatively. Magnetic resonance imaging (MRI) was performed at 2 days and 12 months postoperatively to evaluate the meniscal allograft extrusion and cartilage condition in the lateral compartment. At 12 months, patients with graft extrusion >3 mm on MRI were assigned to the extrusion group.

RESULTS

Significant improvements were observed in the Lysholm and subjective IKDC scores at 12 months postoperatively (both P < .001). The joint space width did not significantly increase (P = .054). Coronal graft extrusion increased significantly (P < .001). At 6 months postoperatively, isokinetic muscle strength tests indicated no significant reduction in the peak torque for knee extension (P = .911). However, at 12 months, the peak torque was significantly increased (P = .001), with the deficits improving from 38.3% to 18.1% (P < .001). No significant changes were noted in the knee flexion strength. Dynamic postural stability showed a significant decrease in the Limb Symmetry Index (LSI) for the anterior reach at 6 months (P = .004), but significant improvements were seen by 12 months, with the LSI values for the anterior, posteromedial, and posterolateral reaches all exceeding 90% (P < .001). No significant differences in muscle strength or dynamic balance were found between the nonextrusion (n = 41) and extrusion (n = 14) groups at 12 months.

CONCLUSION

The significant improvements in isokinetic muscle strength and dynamic postural stability achieved only by 12 months after LMAT underscores the necessity of a comprehensive rehabilitation program and caution against premature sports resumption.

Return-to-sport tests: Do they reduce risk of re-rupture after anterior cruciate ligament reconstruction?

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is one of the most common knee injuries. Despite the effectiveness of reconstruction, re-rupture rates of up to 15 ​% have been reported. Static and dynamic test of strength and movement control have been used to determine when return to sports (RTS) is appropriate.

OBJECTIVE

To determine whether successfully passing return to sport (RTS) tests reduces the re-rupture rate.

METHODS

Retrospective cohort study. Patients who underwent ACL reconstruction (ACLR) from June 2018 to May 2023, and who performed RTS tests after rehabilitation, were analyzed. Patients who, in addition to ACLR, underwent extra-articular tenodesis, osteotomy, or multiligament injuries were excluded. RTS tests included the following: repeat sprint ability, dynamic valgus, proagility, unilateral counter movement jump (CMJ), isokinetic, triple hop test, and functional movement screen (FMS). All statistical analyses were performed with STATA version 18.0.

RESULTS

Ninety five patients underwent RTS tests after ACLR, with a follow-up time of 27.8 months. 71.6 ​% of patients were men with a mean age of 25.15 ​± ​10.7 years. The overall re-rupture rate was 13.68 ​% (13 patients). When comparing patients who passed and did not pass the RTS tests, there were no differences by sex (p ​= ​0.06) or age (p ​= ​0.11). The only statistically significant difference between the groups was the mean risk score (passed: 11.5 ​± ​0.7 vs. not passed: 15.5 ​± ​2.1; p ​< ​0.001). Patients with re-rupture were more likely to be from the non-passed group (passed: 0 ​% v/s not passed: 18.1 ​%; p ​= ​0.03), with a statistical power of 0.70.

CONCLUSION

Our records show that passing RTS test after an ACLR could guarantee the absence of re-rupture in the medium term.

LEVEL OF EVIDENCE

Level IV.

Effectiveness of an intelligent weight-bearing rehabilitation robot in enhancing recovery following anterior cruciate ligament reconstruction

Aim

Orthopedic surgery patients frequently delay early rehabilitation due to postoperative discomfort. This is especially true for younger patients with anterior cruciate ligament injuries who are eager to return to sports after discharge. Despite the recognized benefits of early rehabilitation, a standardized protocol for determining safe weight-bearing timelines post-ACL reconstruction is lacking. This study aims to evaluate the effectiveness of an Intelligent Weight-Bearing Rehabilitation Robot in improving recovery outcomes for these patients.

Design

A retrospective cohort study comparing outcomes between individuals who received the intervention and those in the control group.

Methods

Ninety-two patients who underwent ACL reconstruction were chosen as subjects and separated into two groups: control and intervention, each with 46 patients, in the order of hospital admission. The control group got standard rehabilitation training, whereas the intervention group received rehabilitation training using the Intelligent Weight-Bearing Rehabilitation Robot. The intervention effects of both groups were compared.

Results

The intervention group demonstrated significant improvements in knee joint function post-surgery compared to the control group. The mean range of motion (ROM) in the experimental group increased from 41.63 ± 5.97° pre-intervention to 55.89 ± 5.13° post-intervention, while the control group's ROM improved from 40.65 ± 3.43° to 49.78 ± 5.27° (t = 5.635, p < 0.001). Similarly, the Health Status Score (HSS) increased from 43.07 ± 3.83 to 59.93 ± 3.30 in the experimental group, while the control group showed an increase from 43.76 ± 4.06 to 54.39 ± 4.39 (t = 6.850, p < 0.001). These findings indicate a more substantial recovery in knee joint functionality in the experimental group, suggesting that robotic-assisted rehabilitation facilitated enhanced functional recovery. Additionally, pain reduction was significantly better in the experimental group. At 24 h post-surgery, the Visual Analog Scale (VAS) pain score for the experimental group was 3.45 ± 0.96, compared to 3.98 ± 0.93 in the control group (t = -2.647, p = 0.010). At 48 h, the VAS score in the experimental group was 2.37 ± 0.49, significantly lower than the control group's 3.09 ± 0.66 (t = -5.923, p < 0.001). By discharge, however, the difference in VAS scores between the two groups was no longer statistically significant (p = 0.096). Furthermore, the intervention group had a significantly shorter hospital stay (7.07 ± 0.83 days) compared to the control group (7.96 ± 1.01 days) (t = -4.630, p < 0.001). No complications, such as secondary fractures or deep vein thrombosis, were reported in either group during hospitalization.

Conclusion

Utilizing the intelligent weight-bearing robot in post-ACL reconstruction rehabilitation significantly improves knee function, reduces discomfort, and shortens hospital stay, highlighting the importance of innovation in medical rehabilitation.

Anterior cruciate ligament reconstruction rehabilitation: Decades of change

Current anterior cruciate ligament reconstruction (ACLR) rehabilitation practice guidelines lack updates in key areas: open kinetic chain (OKC) quadriceps strengthening, neurocognitive training and psychological interventions. Recent research shows that OKC exercises, when combined with closed kinetic chain exercises, improve strength without compromising graft integrity, though careful monitoring for knee pain and effusion is essential. Neurocognitive training, targeting reaction times, visual attention and dual-tasking, is promising for reducing reinjury risk but remains underutilized. Similarly, psychological responses, often assessed via patient-reported outcomes, are a critical part of the recovery process after ACLR, but how to address these responses for the individual patient remains unclear, emphasizing the need for individualized support. The European Society for Sports Traumatology, Knee Surgery, and Arthroscopy (ESSKA) is developing an ACL rehabilitation consensus to integrate these insights into actionable, evidence-based guidelines, ensuring tailored, patient-centered care that optimizes recovery and reduces reinjury risks.

Drop landing between subjects post anterior cruciate ligament reconstruction and uninjured controls: A biomechanical and neuromuscular analysis

BACKGROUND

The capacity of functional testing to identify 'at-risk' landing strategies in return to sport evaluation has been questioned. The purpose was to evaluate if biomechanical and muscle activation patterns differ during a drop landing task in subjects post anterior cruciate ligament reconstruction against uninjured controls.

METHODS

22 subjects within two years of anterior cruciate ligament reconstruction who had returned to sport and 25 activity matched controls were recruited. Sagittal plane knee and hip biomechanics and muscle activation amplitudes were recorded during a single leg drop landing task. Discrete measures derived from waveforms were analysed using t-tests and Analysis of Variance models (α=0.05).

FINDINGS

Subjects post anterior cruciate ligament reconstruction displayed reduced knee (Effect Size = 1.2) and hip (Effect Size = 0.995) range of motion as well as reduced knee extension moments (Effect Size = 0.955) but exhibited no differences in quadriceps or hamstrings activation amplitudes versus uninjured controls.

INTERPRETATION

Adoption of reduced knee and hip excursion or "stiffened" landing pattern despite similarities in muscle activation suggests the presence of adaptive strategies reflecting incomplete recovery despite receiving clearance for returned to sport. This suggests presence of altered patterns of movement which may place at increased risk for reinjury.

Combining a digital health application with standard care significantly enhances rehabilitation outcomes for ACL surgery patients

INTRODUCTION

Anterior cruciate ligament (ACL) rupture is one of the most common sports injuries. Regardless of the surgical treatment, patients require intensive education about the pathology, therapeutic options and physical therapy. However, it is often not possible for the patient to start physical therapy directly and schedule adequate consultations. Digital health applications are medical devices that can help bridge the gap between physiotherapy sessions and provide qualified, convenient and effective education and treatment. This study is needed to explore alternative methods to ensure continuous and effective rehabilitation for ACL patients who face delays in accessing traditional physiotherapy. The study aimed to compare app-assisted therapy plus standard of care (conventional orthopaedic and physiotherapeutic measures) versus isolated standard of care for patients with planned ACL surgery.

METHODS

A monocentric, two-arm, 1:1 randomized controlled study examined 80 patients after a cruciate ligament rupture with or without meniscal injury. Patients over 18 years with a confirmed diagnosis of ACL rupture and planned surgical reconstruction using autologous grafts were included. The study criteria additionally included willingness to use the Orthopy app and sufficient German language proficiency. The study excluded patients with severe concomitant injuries, prior knee surgeries, chronic pain conditions and those not compatible with app usage. Patients were randomized and their baseline data (t0) was collected. Subsequently, they received their treatment according to their treatment group. The study included a presurgery period (2-6 weeks) and a postsurgery period (14 weeks). Interim assessments were done via online questionnaires at t1 (if more than 3 weeks before surgery) and t3, t4 and t5 (postsurgery). Additional clinical assessments were conducted at t2 (presurgery) and t6 (14 weeks postsurgery). Primary outcome measures included the knee injury and osteoarthritis outcome score (KOOS), with subjective pain and function levels (numeric rating scale [NRS]) as secondary endpoints.

RESULTS

The clinical trial was able to show positive outcomes on the KOOS Pain and Symptoms subscale of the primary endpoint KOOS in the interventional group compared to the standard of care group. A statistically significant pain reduction could be seen at t1 (p = 0.0005), t2 (p = 0.0068) and t4 (approximately 6 weeks after surgery; p = 0.01). A significant reduction of symptoms at t1 (p = 0.0001), t2 (p = 0.0036) and t6 (p = 0.0377) were recognized. These findings are further supported by the significant benefit of the pain NRS at t4 and positive tendencies at t3, t5 and t6. The KOOS subscales quality of life (p = 0.0066), activities of daily living (p = 0.0009) and Sport (p = 0.0484) showed significant effects before surgery.

CONCLUSION

The Orthopy app is a medical device that is both safe and effective for use. Combining the Orthopy app and standard of care can significantly improve prehabilitation and rehabilitation in surgical treatment with ACL reconstruction compared with the isolated standard of care.

LEVEL OF EVIDENCE

Level I.

Physical therapists' perspectives and clinical practice on assessment, rehabilitation, and return to sport criteria after anterior cruciate ligament injury and reconstruction in Saudi Arabia

Background and objectivesTo explore the physical therapists' (PTs) perspectives and clinical practice on assessment, rehabilitation, and return to sports (RTS) criteria and to investigate their associations with gender, level of educational qualification, years of clinical experience, and the number of individuals treated after ACL injury and reconstruction (ACLR) in Saudi Arabia (SA).MethodsThis descriptive cross-sectional study surveyed 206 participants through an online survey covering demographics, ACLR rehabilitation importance, clinical measurements, practice, progression criteria, return to running, and RTS.ResultsMost PTs (84.9%) see an individual post-ACLR for the first time within the first week. About 24.8% of PTs preferred starting open kinetic chain (OKC) exercises one to seven days immediately post-ACLR. The timing of returning to running post-ACLR is variable among participants. Between six to nine months, 39.8% of PTs allowed an individual post-ACLR to RTS. Over 40% of participants did not use patient-reported outcome measures (PROMs) to clear an individual post-ACLR to RTS or evaluate psychological readiness. About 76.2% recommended an ACL injury prevention program at discharge.ConclusionMost PTs in SA inconsistently follow evidence-based ACLR rehabilitation practices. Education and training programs are needed to bridge the evidence-to-practice gap in post-ACLR care.

Assessing the Predictive Value of Preoperative Knee Function Tests and Self-Report Scores in Anterior Cruciate Ligament Injury Recovery

BACKGROUND

The ability to identify patients with long-term poor outcomes using clinical and functional information is limited. Identifying prognostic factors to improve long-term outcomes after anterior cruciate ligament (ACL) injury can influence and inform targeted interventions for this population.

HYPOTHESIS

Preoperative functional tests and patient-reported outcome measures are predictive of postoperative functional recovery and satisfaction in patients undergoing first-time ACL repair, second-time ACL repair on the same knee, and bilateral ACL repair.

STUDY DESIGN

Quasi-experimental prospective study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 88 patients with ACL reconstruction were included. Subjective knee scoring systems and functional performance tests were used for evaluation and analyzed for correlation with results.

RESULTS

The first time ACL injury group had lower scores in the various self-report scales: Knee injury and Osteoarthritis Outcome Score (KOOS), Lysholm Rating Scale, International Knee Documentation Committee (IKDC), and Lower Extremity Functional Scale (LEFS).

CONCLUSION

Reduction in self-reported knee function and Y balance test performance after ACL injury are predictive factors for recovery. Estimates exceeded clinically important thresholds. Those who had already undergone surgery had clinically better thresholds, highlighting the assessing these measures when designing presurgical rehabilitation programs.

Anterior Cruciate Ligament Return to Play: "A Framework for Decision Making"

Anterior cruciate ligament (ACL) injury is common in athletic individuals and often leads to physical impairments, a low rate of return to performance, reinjuries, and sometimes reductions in career length [...].

Neuromuscular Control Deficits After Anterior Cruciate Ligament Reconstruction: A Pilot Study Using Single-Leg Functional Tests and Electromyography

Purpose: This study aimed to evaluate neuromuscular control and muscle activation patterns in individuals following anterior cruciate ligament (ACL) reconstruction, compared to healthy controls. Methods: A cross-sectional comparative study was conducted following STROBE guidelines, including 16 participants (ACL group: n = 9; control group: n = 7). Participants performed the single-leg squat (SLS) test and the single-leg drop landing (SLDL) test. Neuromuscular control was assessed using the Qualitative Analysis of Single-Leg Loading Score (QASLS), while gluteus medius and vastus medialis activation were recorded using surface electromyography. Results: The ACL group showed significantly higher QASLSs in the SLS test (p = 0.0113), indicating poorer movement quality, while no difference was found in the SLDL test (p = 0.5484). Gluteus medius activation was lower in the ACL group during the SLS test (p = 0.0564), and vastus medialis activation was higher but not significantly different (p = 0.095). Conclusions: These findings highlight persistent neuromuscular deficits post-ACL-reconstruction, particularly in SLS tasks, reinforcing the need for targeted rehabilitation strategies focusing on hip stabilization and quadriceps motor control to optimize movement quality and reduce reinjury risk.

Effects of Asymmetric and Symmetric Sport Load on Upper and Lower Extremity Strength and Balance: A Comparison Between the Dominant and Non-Dominant Side in Adolescent Female Athletes

The aim of this research was to investigate the effects of primarily asymmetrical (soccer and volleyball) and symmetrical sport load (sprint and swimming) in the upper and lower limbs on dynamic balance and muscle strength and to compare these values in the dominant and non-dominant limbs. This study employed a cross-sectional design, included 45 adolescent female athletes from four sports, divided into asymmetric (ASYM, n = 25) and symmetric (SYM, n = 20) groups. They were assessed for maximal voluntary isometric muscle contraction (MVIC) relative muscular strength using a handheld dynamometer (HHD) for shoulder external rotation (ER) and internal rotation (IR), as well as hamstring and quadricep strength. Upper and lower limb balance were also assessed using the Upper (YBT-UQ) and Lower Quarter Y Balance Test (YBT-LQ) tests. The results showed significantly greater balance in the upper extremities of swimmers and in the lower extremities of the sprinters in both the dominant (DS) and non-dominant (NDS) sides than in other groups (p < 0.0001). However, no significant difference in internal and external shoulder rotator muscles strength between the groups (p > 0.05). Although significant differences were found in hamstring strength on the dominant side and quadricep strength on both sides (p < 0.05), a notable finding was that sprint athletes consistently demonstrated stronger quadriceps muscles as compared to other groups in both the dominant and non-dominant sides. According to the current findings, there are significant differences in upper and lower body balance, hamstring, and quadricep muscle strength among sports. This suggests that athletes of asymmetrical sports may need to improve non-dominant side knee strength and balance symmetry to prevent the risk of injury.

Positive impact of patient participation in arthroscopic anterior cruciate ligament reconstruction surgery on clinical and functional outcomes, rehabilitation and patient satisfaction

BACKGROUND

This study aimed to evaluate the effect of patient participation on clinical and functional outcomes, satisfaction, and compliance with postoperative rehabilitation in patients undergoing surgery for anterior cruciate ligament (ACL) injury.

METHODS

Sixty-one patients who underwent isolated ACL reconstruction (ACLR) were included. Thirty patients in the participation group were shown the arthroscopy screen and allowed to communicate with the surgeon during surgery. For clinical and functional evaluation, knee joint range of motion (ROM), International Knee Documentation Committee Subjective Knee Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Lysholm Knee Scoring Scale (LKSS), Short Form-36 (SF-36) score, and Tegner Activity Scale (TAS), were used. The Pain Quality Assessment Scale was used to assess pain. Additionally, the patient's satisfaction and exercise compliance were evaluated using a 5-point Likert scale and percentage of exercise participation, respectively.

RESULTS

At 3rd week, the ROM, SF-36, LKSS values, and pain scores were better in the participation group compared to the control group(p <.05). At 6th month, the IKDC, KOOS, SF-36 values and pain scores were also better in the participation group compared to the control group (p <.05). However, the ROM, LKSS, and TAS values were similar between groups at the 6th month(p >.05). Postop satisfaction at 3rd week and 6th month and exercise compliance postoperatively were significantly better in the participation group compared to the control group(p <.05).

CONCLUSION

Patient participation during ACLR surgery by communicating with the surgeon positively affects clinical and functional outcomes. It also contributes to patient satisfaction and compliance with the rehabilitation program postoperatively.

CLINICAL TRIAL NUMBER

Not Applicable.

Rehabilitation volume, psychological readiness, and motor function are important factors for a successful return to sport after anterior cruciate ligament reconstruction: A 2-year follow-up cohort study

OBJECTIVES

To find contributors to return to sport success or time until return to sport in individuals after an anterior cruciate ligament reconstruction.

DESIGN

Cohort study.

METHODS

Secondary analysis of the data of two intervention studies.

PARTICIPANTS

We included adults < 36 years of age with a tendon autograft anterior cruciate ligament reconstruction who were active in any type of sport prior to the injury and aiming to return to sport. All participants were prospectively monitored for 24 months.

INTERVENTIONS

At the end of the individual post-surgery rehabilitation and re-injury prevention programmes, self-report- and objective functional outcomes were quantified.

MAIN OUTCOME MEASURES

The potential return to sport success (return to the same type of sports, frequency, intensity, and quality of performance as pre-injury), secondary injuries, and all rehabilitation and training measures were prospectively monitored. To determine the contributing factors, Cox regressions for traits and baseline factors and a logistic mixed model, which also included prospective time-dependent factors, were calculated.

RESULTS

203 participants were included; 104 (51 % of the total sample and 68 % of the full cases) successfully returned to their sporting activity. The median duration until return to sport was 302 days (interquartile range was 114 days). Contributing factors were the type of working (blue- vs. white collar: odds ratio for return to sport = 0.51 [95 % confidence interval = 0.29 to 0.90]) and the athletic status (elite vs. non-elite: odds ratio = 2.28 [1.03 to 5.03]). Prospectively, higher rehabilitation volumes until the end of the rehabilitation were predictive for return to sport success: the odds ratio per additional hour of rehabilitation was 1.004 [1.001 to 1.006]. Functional abilities such as the normalised knee separation distance during drop jump landing (odds ratio = 0.961 [0.924 to 0.999]) were predictive at a later stage, at the end of the re-injury prevention. Psychological readiness for return to sport was predictive at most of the timepoints: those who were confident to return to sport were more successful to return to sport at the end of the rehabilitation (odds ratio = 1.029 [1.004 to 1.056]) and at the end of the re-injury prevention (odds ratio = 1.038 [1.004 to 1.073]).

CONCLUSIONS

The most important factors for a successful pre-injury-level return to sport after anterior cruciate ligament reconstruction were the exercise volume, psychological readiness and functional hop/jump abilities. Whilst the impact of these modifiable factors was robust against multilevel modelling, the impact of athletic and working status vanishes when the prospective factors are included.

Questioning the rules of engagement: a critical analysis of the use of limb symmetry index for safe return to sport after anterior cruciate ligament reconstruction

OBJECTIVE

To evaluate the association between limb symmetry index (LSI) in quadriceps and hamstrings strength together with hop tests, as a proxy of recovery, and the deviation from being symmetrical (LSI 100%), with a safe return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R).

METHODS

Athletes between 15 and 30 years old with a preinjury Tegner activity level ≥6 were eligible for inclusion. Data were extracted from a rehabilitation-specific registry, Project ACL (Gothenburg, Sweden) at the time of or after RTS for each athlete. The outcome of interest in this study was a safe RTS-not suffering a second ACL injury within 2 years from RTS-addressed by using the LSI in five different ways with results from the test battery which include five tests of muscle function at or after the time of RTS. Logistic regression analyses were performed with safe RTS as a dependent variable and presented with ORs and 95% CIs.

RESULTS

In total, 233 athletes (51.1% women) were included. The best-differentiating cut-offs for strength and hop tests showed non-significantly poor discriminatory ability between athletes who had a safe RTS and those who did not (Youden J 0.09-0.24 and area under the curve 0.50-0.59). Athletes who had ≥80% or ≥85% LSI had significantly lower odds of safe RTS compared with athletes who did not meet the cut-offs of safe RTS (OR=0.32 (95% CI 0.12 to 0.87) and OR=0.39 (95% CI 0.18 to 0.84), respectively). There was no effect of a 1% increase in LSI or deviation from 100% symmetry on safe RTS.

CONCLUSION

The use of LSI from tests of muscle function to determine safe RTS after ACL-R, that is, RTS without sustaining a second ACL injury within 2 years, cannot differentiate between athletes who had a safe RTS and those who did not, regardless of whether LSI was used as cut-offs, incremental or as deviation from symmetry. Thus, it is of clinical importance that clinicians do not solely rely on the LSI to clear athletes for RTS.

Symptoms indicative of early knee osteoarthritis after ACL reconstruction: descriptive analysis of the SHIELD cohort

Objective

To describe the SHIELD cohort in terms of symptoms indicative of early knee osteoarthritis (OA) and to investigate associations between patient characteristics (demographics, activity/injury-related) and these symptoms at 1 (cross-sectional) and 3 years (longitudinal) post anterior cruciate ligament reconstruction (ACLR).

Method

106 participants (50 ​% women, mean [SD] age 25 [5] years) were included. Symptoms indicative of early knee OA were evaluated by the Knee injury and Osteoarthritis Outcome Score (KOOS) subscale pain, KOOS subscale pain ≤72 (KOOSpain ≤72), and ≤85 on two out of four KOOS subscales (pain, symptoms, activity of daily living, quality of life) (modified Luyten).

Results

Mean (SD) KOOS pain scores were 83.2 (15.7) and 87.3 (12.7) at 1 and 3 years, respectively. At 1 year and 3 years post ACLR, 18/101 (18 ​%) and 14/86 (16 ​%) participants met the KOOSpain ≤72 criterion, whereas 83/101 (82 ​%) and 67/86 (78 ​%) met the modified Luyten criterion. 7/15 (47 ​%) (KOOSpain ≤72) and 59/70 (84 ​%) (modified Luyten) classified as having knee OA symptoms 1 year post ACLR were still classified as having OA symptoms after 3 years. Lower activity level at 1 year was the sole variable consistently associated with all three outcomes 3 years post ACLR.

Conclusion

The proportion of participants fulfilling existing classification criteria for symptoms indicative of early OA after ACLR is highly dependent on the criteria applied and different criteria seem to capture varying aspects of early OA symptoms. Future studies will reveal if these symptoms will persist long-term or just reflect more transient issues.

Effect of open kinetic chain exercises during the first weeks of anterior cruciate ligament reconstruction rehabilitation: A systematic review and meta-analysis

BACKGROUND

Closed kinetic chain (CKC) exercises are the gold standard for rehabilitation after anterior cruciate ligament reconstruction (ACL-R). Open kinetic chain (OKC) exercises may provide benefits, but their use in the early stages remains controversial.

OBJECTIVE

To determine the effect of OKC exercises during the first weeks of rehabilitation after ACL-R.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A comprehensive literature search was conducted according to PRISMA guidelines from inception to April 2024. The methodological quality of the included studies was assessed using the ROBINS I and RoB-2 tools. The changes in outcomes from pre-to post-intervention were quantified using standardized mean differences.

RESULTS

Overall, the methodological quality was low and the population, intervention, comparison, outcome, time (PICOT) criteria were heterogeneous. However, OKC was found to have beneficial effects on patient reported outcomes (PROMs), strength, function, and return to play, especially when performed at least four weeks after surgery in rehabilitation programs that began with CKC exercises.

CONCLUSION

The evidence suggests that OKC exercises may provide benefits and no adverse effects in the early stages of rehabilitation after ACL-R, particularly when initiated after CKC exercises. These findings are consistent with current clinical practice guideline recommendations for the inclusion of OKC in rehabilitation programs.

fMRI Activation in Sensorimotor Regions at 6 Weeks After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Brain activity during knee movements is altered throughout the sensorimotor network after anterior cruciate ligament reconstruction (ACLR). Patients at 2 to 5 years after surgery appear to require greater neural activity to perform basic knee movement patterns, but it is unclear if brain activity differences within sensorimotor regions are present early after surgery. It is also unknown whether uninvolved knee movements elicit similar or unique activity compared with involved knee movements.

PURPOSE

To examine brain activity in sensorimotor regions during involved and uninvolved knee movements in patients at 6 weeks after ACLR compared with control participants.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 15 patients who underwent ACLR (mean age, 21.9 ± 4.3 years [range, 17-29 years]; 8 female) and 15 control participants performed 30-second blocks of repeated knee flexion and extension, followed by 30 seconds of rest, during functional magnetic resonance imaging. Regions of interest included the right and left primary motor cortex (M1), right and left primary somatosensory cortex (S1), supplementary motor area (SMA), precuneus, and lingual gyrus. Activity from task-relevant voxels (move > rest) was extracted, and generalized estimating equations evaluated the main effect of group and group-by-limb interaction. Effect sizes were calculated using the Cohen d.

RESULTS

Reduced brain activity during knee flexion and extension was observed in the ACLR group in the ipsilateral M1 and S1, contralateral S1, SMA, and precuneus during movements of the involved and uninvolved knees. There were no group-by-limb interaction effects, indicating no significant differences between the involved knee and uninvolved knee in the ACLR group. Medium to large effect sizes were identified for between-group differences in all regions.

CONCLUSION

At 6 weeks after ACLR, patients exhibited bilateral reductions in brain activity during knee movements in multiple sensorimotor regions. These identified regions are associated with motor planning, motor execution, somatosensory function, and sensorimotor integration. These data indicate that ACLR affected sensorimotor brain activity in both limbs during the early postoperative phase of rehabilitation.

Sex Differences in Quadriceps Atrophy After Anterior Cruciate Ligament Tear

BACKGROUND

Female athletes lag behind their male counterparts in recovery from anterior cruciate ligament (ACL) injury. Quadriceps muscle size and strength are crucial factors for regaining function after ACL injury, but little is known about how these metrics vary due to biological sex.

HYPOTHESIS

Female patients have reduced vastus lateralis fiber cross-sectional area (CSA) and lower quadriceps strength after ACL injury than male patients.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A total of 60 participants with recent ACL tear were evaluated for vastus lateralis muscle fiber CSA, isometric quadriceps peak torque, and quadriceps rate of torque development. Linear mixed models were fit to determine differences across sex and limb for each variable of interest.

RESULTS

The female group averaged almost 20% atrophy between limbs (P < 0.01), while the male group averaged just under 4% (P = 0.05). Strength deficits between limbs were comparable between female and male groups.

CONCLUSION

Immediately after ACL injury, female patients have greater between-limb differences in muscle fiber CSA but between-limb strength deficits comparable with those of male patients.

CLINICAL RELEVANCE

These results indicate that the underpinnings of strength loss differ based on biological sex, and thus individual patients could benefit from a sex-specific treatment approach to ACL injury.

Anterior Cruciate Ligament Reconstruction Return to Sport Testing Passing Rates for Healthy People: A Systematic Review

BACKGROUND

Return to sport (RTS) is a common goal after anterior cruciate ligament (ACL) reconstruction (ACLR) but carries a relatively high risk of reinjury with up to 20% to 25% of athletes experiencing graft rupture or contralateral ACL tear. While there is increased emphasis on establishing safe RTS criteria for athletes to return to previous activity levels, studies show that even healthy individuals have difficulty passing RTS testing.

PURPOSE

To synthesize data concerning whether healthy individuals can pass ACLR RTS rehabilitation tests.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Following the established PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors conducted a systematic literature search in May 2023. Three databases were used in the search (PubMed, EMBASE, and SPORTDiscus) to retrieve all studies that conducted ACLR RTS rehabilitation tests on healthy individuals. Tests included were isometric strength, isokinetic strength, hop, and balance tests. The search was performed in duplicate, and a quality assessment of all studies was included.

RESULTS

A total of 1724 studies were retrieved, of which 32 were included, involving 1552 controls with no history of ACL injury. From the studies analyzed, 5.3% to 42.2% of healthy participants failed 6 different hop tests, 15.2% failed the Star Excursion Balance Test, 37% failed the isometric knee flexion test, 50% failed the isometric knee extension test, and 23.7% to 28.9% failed the drop vertical jump test. An asymmetry index ≥10% was found in 6 of the 18 isokinetic tests and 2 of the 14 isometric tests. Hop testing was the most common test in the included studies (56.3%), followed by balance testing (31.3%), isometric strength testing (31.3%), isokinetic strength testing (25%), and drop vertical jump (6.3%).

CONCLUSION

Many healthy individuals fail ACLR RTS tests, with some having an inherent variation from side to side that is >10%. The passing threshold for RTS testing should be a value that is practical yet helps reduce reinjury rates.

Hamstrings and Quadriceps Weaknesses Following Anterior Cruciate Ligament Reconstruction Persist Up to 6 Months After Return-to-Sport: An Angle-specific Strength Analysis

BACKGROUND

Hamstrings and quadriceps strength recovery and restoration of the hamstrings-to-quadriceps ratio (H/Q ratio) is a major concern after anterior cruciate ligament reconstruction (ACLR). Recently, moment-angle profiles and angle-specific H/Q ratios are receiving increasing interest.

PURPOSE

The first objective of this study was to investigate moment-angle profiles and angle-specific H/Q ratio profiles in athletes with ACLR at the time of RTS. The second objective of this study was to assess whether strength asymmetries identified at the time of RTS, persist after six months.

STUDY DESIGN

Case-Control study.

METHODS

Twenty athletes who had undergone ACLR performed isokinetic strength tests for concentric knee flexion and extension (60°/s) at RTS, and three and six months later. Twenty controls were tested once. T-tests were used to compare strength differences between 1) ACLR athletes and controls and 2) the injured and uninjured leg of the ACLR athletes. Finally, to assess strength deficits over time, two-way ANOVAs were used.

RESULTS

Angle-specific analyses and peak moments showed lower hamstrings strength in the injured leg of ACLR athletes compared to their uninjured leg at RTS. Furthermore, angle-specific analyses showed a lower hamstrings strength and H/Q ratio in the injured leg compared to controls at larger knee flexion angles. The latter deficit was not identified with a peak-based analysis. The asymmetries identified at RTS did not change over the six months following RTS.

CONCLUSIONS

Athletes with ACLR show strength deficits and asymmetries that persist even six months after RTS. As some asymmetries may go undetected by peak-based analyses, angle-specific analyses are recommended.

LEVEL OF EVIDENCE

Level 3b.

Early Gait Biomechanics Linked to Daily Steps After Anterior Cruciate Ligament Reconstruction

CONTEXT

Gait biomechanics and daily steps are important aspects of knee-joint loading that change after anterior cruciate ligament reconstruction (ACLR). Understanding their relationship during the first 6 months post-ACLR could help clinicians develop comprehensive rehabilitation interventions that promote optimal joint loading after injury, thereby improving long-term knee-joint health.

OBJECTIVES

To compare biomechanical gait waveforms throughout stance at early time points post-ACLR in individuals with different daily step behaviors at 6 months post-ACLR and to examine how these gait waveforms compare with those of uninjured controls.

DESIGN

Case-control study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 32 individuals with primary ACLR assigned to the low-step group (LSG; n = 13) or the high-step group (HSG; n = 19) based on their average daily steps at 6 months post-ACLR and 32 uninjured matched controls.

MAIN OUTCOME MEASURE(S)

Gait biomechanics were collected at 2, 4, and 6 months post-ACLR for the ACLR groups and at a single session for the control group. Knee-adduction moment, knee-extension moment (KEM), and knee-flexion angle (KFA) waveforms were calculated during gait stance and then compared via functional waveform analyses. Mean differences and corresponding 95% CIs between groups were reported.

RESULTS

Primary results demonstrated less KFA (1%-45% versus 79%-92% of stance) and greater KEM (65%-93% of stance) at 2 months and greater knee-adduction moment (14%-20% versus 68%-92% of stance) at 4 months post-ACLR for the HSG compared with the LSG. Knee-adduction moment, KEM, and KFA waveforms differed across various proportions of stance at all time points between the step and control groups.

CONCLUSIONS

Differences in gait biomechanics were present at 2 and 4 months post-ACLR between step groups, with the LSG demonstrating an overall more flexed knee and more profound stepwise underloading throughout stance than the HSG. The results indicate a relation between early gait biomechanics and later daily step behaviors post-ACLR.

Bilateral waveform analysis of gait biomechanics presurgery to 12 months following ACL reconstruction compared to controls

The purpose of this study was to compare gait biomechanics between limbs and to matched uninjured controls (i.e., sex, age, and body mass index) preoperatively and at 2, 4, 6, and 12 months following primary unilateral anterior cruciate ligament reconstruction (ACLR). Functional mixed effects models were used to identify differences in gait biomechanics throughout the stance phase between the a) ACLR limb and uninvolved limb, b) ACLR limb and controls, and c) uninvolved limb and controls. Compared with the uninvolved limb, the ACLR limb demonstrated lesser knee extension moment (KEM; within 8-37% range of stance) during early stance as well as lesser knee flexion moment (KFM; 45-84%) and greater knee flexion angle (KFA; 43-90%) during mid- to late stance at all timepoints. Compared with controls, the ACLR limb demonstrated lesser vertical ground reaction force (vGRF; 5-26%), lesser KEM (7-47%), and lesser knee adduction moment (KAM; 12-35%) during early stance as well as greater vGRF (39-63%) and greater KFA (34-95%) during mid- to late stance at all timepoints. Compared with controls, the uninvolved limb demonstrated lesser KFA (1-56%) and lesser KEM (12-54%) during early to mid-stance at all timepoints. While gait becomes more symmetrical over the first 12 months post-ACLR, the ACLR and uninvolved limbs both demonstrate persistent aberrant gait biomechanics compared to controls. Biomechanical waveforms throughout stance can be generally described as less dynamic following ACL injury and ACLR compared with uninjured controls.

The Effect of Blood Flow Restriction Training on Quadriceps Muscle Strength and Functional Performance Following Isolated Anterior Cruciate Ligament Reconstruction: A Pilot Study

BACKGROUND

Quadriceps weakness is common after anterior cruciate ligament (ACL) injuries and ACL reconstruction (ACLR). Blood flow restriction (BFR) training is being increasingly used during ACLR rehabilitation protocols to facilitate a hypoxic cellular environment that triggers a local stress response theorized to promote muscle hypertrophy, and thus muscle strength, without mechanically loading a healing ACL graft. While BFR is a popular addition to therapy, scientific methods used to examine BFR training following ACLR have been inconsistent or insufficient to determine whether early BFR has a significant therapeutic effect on strength and function, and few studies have used advanced imaging to assess changes in muscle volume and composition.

PURPOSE

This study aimed to investigate changes in postoperative quadriceps strength and muscle volume between conventional ACLR rehabilitation with early BFR training and conventional ACLR rehabilitation with sham (e.g., non-therapeutic pressure) BFR training. We secondarily sought to evaluate the effect of early BFR training on late-stage functional and patient-reported outcomes (PROMs).

METHODS

Ten individuals with a unilateral isolated ACLR were randomized to receive 200 minutes of BFR or sham (CON) training as part of their ACLR rehabilitation protocol. Quadriceps and hamstring strength were taken via a handheld dynamometer to calculate limb symmetry indices (LSI) at eight and 36 weeks postoperatively. Magnetic resonance (MR) images were acquired of the bilateral knees pre- and post-BFR or CON training and evaluated for muscle volume and adipose composition. Single-leg hop tests were performed at the conclusion of the rehabilitation protocol around 36 weeks postoperatively. PROM measures were measured by the International Knee Documentation Committee (IKDC) and Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and eight and 36 weeks postoperatively.

RESULTS

At eight weeks postoperatively, there was not a significant difference in quadriceps and hamstring LSI between the BFR and CON groups. At 36 weeks postoperatively, there was a significant increase in strength within all groups, but there were no significant differences in the improvement of either quadriceps or hamstring strength between the BFR and CON groups. There was no significant change in quadriceps intramuscular adipose composition or muscle volume between pre- and post-BFR MR images within the BFR group. There was additionally no difference between PROMs and adverse events between the two groups at the eight- and 36-week postoperative time points, and there were no complications with early BFR use.

CONCLUSION

In this pilot study, quadriceps and hamstring strength, muscle volume, and intramuscular adipose were not impacted over time or between the BFR and standard-of-care groups. Early BFR utilization had no effect on PROMs between BFR and standard of care as measured by IKDC and KOOS. Larger studies are needed to better understand the potential effects of early BFR on patient rehabilitation after ACLR.

Clinical Practice Guideline Development in Pediatric Emergency Medicine Departments Across the United States: A Cross-sectional Study

OBJECTIVE

This cross-sectional study aimed to assess the process of clinical practice guideline (CPG) development in pediatric emergency medicine departments (PEDs) across the United States, with a focus on identifying areas for improvement to enhance the quality of CPGs.

METHODS

An electronic survey was distributed to PEDs with pediatric emergency medicine fellowship programs. Respondents were asked about their CPG development processes (ie, guideline committee composition, consideration of conflicts of interest, grading recommendations, guideline training opportunities) based on the Appraisal of Guidelines, Research, and Evaluation (AGREE II) tool as well as implementation and monitoring. Univariate analysis was used to assess associations between the number of AGREE II elements adhered to and annual patient volume.

RESULTS

Of the 84 PEDs surveyed, 44 (52.4%) responded, representing institutions from 28 states. Most PEDs (97.7%, n = 43) reported developing their own guidelines, citing the need to improve care quality and standardize patient care as primary reasons. Although most guideline committees included multidisciplinary team members (74.4%, n = 32), routine patient involvement in committees was rare (11.6%, n = 5), and barriers such as time and resource constraints hindered their inclusion. Formal training for committee members in guideline development was uncommon (18.6%, n = 8). There was an association between higher annual patient volume and the number of AGREE II elements adhered to ( P = 0.03). Few PEDs considered potential conflicts of interest among committee members (13.6%, n = 6). Over half of surveyed PEDs (54.5%, n = 24) lacked a systematic approach to grading recommendations. Educational materials and workshops were the most common guideline implementation strategies.

CONCLUSIONS

Our findings highlight need for improvement in the CPG development process in PEDs. Including patients in committees, providing formal training for committee members, and adopting a rigorous approach to grading recommendations are crucial steps toward enhancing guideline quality. Emphasizing these improvements has the potential to improve the quality of CPGs for pediatric emergency care.

The effects of contralateral limb cross-education training on post-surgical rehabilitation outcomes in patients with anterior cruciate ligament reconstruction: a randomized controlled trial

OBJECTIVE

This study examines whether cross-education training of the healthy limb promotes cross-transfer through central nervous system stimulation, enhancing the function, kinematic parameters, dynamic balance, and plantar pressure of the affected knee joint in patients recovering from postoperative anterior cruciate ligament reconstruction (ACLR).

METHODS

Forty anterior cruciate ligament reconstruction (ACLR) patients, 5-6 weeks postoperatively, were included and randomly assigned to either an experimental group (n = 20) or a control group (n = 20). The experimental group participated in six weeks of cross-education (CE) training in addition to conventional rehabilitation, while the control group received only conventional rehabilitation. Assessment outcomes included knee function (Lysholm score, joint mobility, and surface electromyographic characteristics of the rectus femoris muscle), kinematic parameters (stride length, stride speed, and stride width), dynamic balance (gait line length, single-support line length, and medial-lateral displacements), and plantar pressure (forefoot, midfoot, and hindfoot pressures). The effect of CE training on postoperative ACLR rehabilitation was comprehensively assessed by comparing the pre- and post-intervention changes within each group and the differences between the groups.

RESULTS

Before the intervention, no statistically significant differences were observed between the two groups across all measured parameters (P > 0.05). Following the intervention, significant improvements in knee function, kinematic parameters, balance function, and plantar pressure were observed in both groups, with the experimental group showing significantly more significant improvements (P < 0.05). The Lysholm score, range of motion (ROM), and surface electromyographic activity of the rectus femoris muscle were significantly higher in the experimental group compared to the control group (P < 0.01). Among kinematic parameters, the experimental group demonstrated a significant increase in stride length and reduced stride width, whereas differences in stride speed were not statistically significant (P > 0.05). Regarding balance function, the experimental group exhibited significantly longer gait and single-support line lengths, significantly reducing medial-lateral displacement (P < 0.05). Analysis of plantar pressure revealed significant improvements in forefoot and hindfoot pressures in the experimental group, with a particularly notable increase in hindfoot pressure (P < 0.05). However, changes in midfoot pressure were not statistically significant (P > 0.05).

CONCLUSION

CE training markedly enhanced knee function, kinematic metrics, dynamic stability, and plantar pressure in postoperative ACLR patients providing initial evidence for the prospective utilization of CE theory in rehabilitation. Nonetheless, the fundamental mechanics of its effects remain ambiguous, and variables such as individual differences and neuromuscular adaptation processes may affect training results. Future studies should examine its long-term impacts and uncover potential neuromuscular pathways to establish a solid scientific basis for improving postoperative rehabilitation procedures.

How effective is the addition of specific exercise therapy for patients after anterior cruciate ligament surgery? A systematic review and meta-analysis

Context

Anterior cruciate ligament (ACL) injuries are prevalent in sports and often require surgical intervention followed by rehabilitation. Several rehabilitation methods have been used for patients after ACL surgery.

Objective

This study aimed to assess the overall efficacy of exercise therapy in improving outcomes for patients following ACL surgery using a systematic review and meta-analysis of randomized controlled trials (RCTs).

Data sources

PubMed, Web of Science, Embase, and the Cochrane Library were searched for randomized controlled trials published from 1 January 2000 to 30 August 2024. Study quality was assessed using the Cochrane Risk-of-Bias tool.

Study selection

A total of 11 randomized controlled trials (whole-body vibration training = 4, core-stability training = 2, strength training = 3, blood flow restriction training = 1, and aquatic training = 1) involving 552 anterior cruciate ligament surgery patients were included.

Data extraction

Two researchers individually screened the key information for each eligible study and evaluated the quality of the studies. Any dispute was discussed by a third researcher.

Results

Compared with conventional therapy, exercise therapy significantly reduced pain scores (mean difference: -0.53, 95% CI: -0.82 to -0.24, and p < 0.001) and improved muscle strength (flexion: 13.76 and extension: 12.46) and knee function (effect size: 2.06 and p = 0.001). Secondary outcomes, although less pronounced, also demonstrated improvement.

Limitation

The sources of heterogeneity among the included studies were not fully identified, particularly concerning variations in exercise protocols or patient characteristics. Additionally, the therapeutic effects of specific exercise modalities (e.g., strength training versus aquatic training) were not directly compared.

Conclusion

Exercise therapy is effective in reducing pain, enhancing muscle strength, and improving knee function in ACL surgery patients. These findings underscore the importance of integrating tailored exercise therapies into rehabilitation programs.

Systematic review registration number

https://www.crd.york.ac.uk/PROSPERO/, identifier registration number. CRD42023476653.

Return to preinjury pivoting sports after anterior cruciate ligament reconstruction is different between males and females, as are the patient-reported reasons

PURPOSE

To investigate return to sport (RTS) after anterior cruciate ligament reconstruction (ACLR), differences based on sex and concomitant meniscal repair, and identify reasons why patients do not RTS.

METHODS

Overall, 232 patients undergoing ACLR, with or without concomitant meniscal repair, that were actively participating in pivoting sports at the time of injury, were prospectively recruited. At 2 years, return to preinjury pivoting sport was investigated and, if they had returned, whether they felt their performance was at (or better) or below preinjury status. Specific reasons for not returning were identified. RTS rates and reasons for not returning were compared based on sex and meniscal repair.

RESULTS

Overall, 140 patients (60.3%) had returned to their preinjury pivoting sport, of which 98 (70.0%) felt they were performing at (or beyond) preinjury status. While a significantly greater (p = 0.024) percentage of males (66.9%) versus females (52.4%) had returned to pivoting sports by 2 years, no differences (p = 0.708) were seen based on concomitant meniscal repair. Overall, 92 patients (39.7%) had not RTS, with primary reasons being loss of interest (21.7%), too busy due to their work and/or family environment (22.8%), or fear of reinjury or lacking confidence (17.4%). Other less-reported reasons included ongoing knee issues (6.5%) or not feeling physically ready (5.4%).

CONCLUSIONS

This study outlined specific reasons why community-level patients do not RTS, with RTS status (and reasons for not returning to preinjury pivoting sports) differing between males and females, with the latter returning at a significantly lower rate overall.

LEVEL OF EVIDENCE

Level IV.

Loaded Open Kinetic Chain Exercises Caused More Anterior Tibial Translation and Anteromedial Graft Elongation Than Closed Kinetic Chain Following Double-Bundle Anterior Cruciate Ligament Reconstruction

CONTEXT

To further improve rehabilitation programs while preventing overstretching the anterior cruciate ligament (ACL), a thorough understanding of the knee kinematics and ACL length change during closed kinetic chain and open kinetic chain (OKC) exercises is essential. The measurement of ACL graft length relates to the changes in strain experienced by the ACL graft during different types of exercises rather than simple physical length.

OBJECTIVE

This study aimed to determine the effects of closed kinetic chain and OKC exercises on tibiofemoral kinematics and ACL graft length changes following double-bundle ACL reconstruction.

DESIGN

Cohort study (diagnosis); level of evidence, 3.

SETTING

Laboratory.

PATIENTS

Fifteen patients who underwent double-bundle ACL reconstruction were asked to perform 10-kg loaded seated knee extension (OKC-10) and single-leg lunge. During the seated knee extension, patients were instructed to extend and flex the knee within a range of 0° to 90° of flexion, with a 10-kg load applied to the ankle. For the lunge, patients began in a natural standing position and were instructed to flex the ACL-reconstructed knee to approximately 90°.

INTERVENTIONS

The 3-dimensional tibiofemoral kinematics under different weight-bearing conditions were determined using a dual-fluoroscopic imaging system.

MAIN OUTCOME MEASURES

The tibiofemoral kinematics in 6 degrees-of-freedom were measured. And 3-dimensional ligament simulation technique was used to quantify length changes of the anteromedial bundle and posterolateral bundle.

RESULTS

The tibia exhibited significantly more external rotation during the OKC-10 motion than during the single-leg lunge from 35° to 70° of knee flexion (P ≤ .028). Beyond 30° of knee flexion, the tibia exhibited significantly more varus during the OKC-10 motion than during the single-leg lunge (P ≤ .028). And a significantly more anterior tibial translation was observed during the OKC-10 motion than during the lunge from 0° to 15° of flexion (P ≤ .018). The anteromedial bundle length was significantly longer during the OKC-10 motion than during the lunge between 0° and 25° of knee flexion (P ≤ .028).

CONCLUSIONS

The effects of OKC exercises with loads on knee rotational stability should be considered in making rehabilitation programs for patients after ACL reconstruction. Since some degree of anterior tibial translation is physiological, it is important to note that increased translation alone does not necessarily indicate danger or instability.

Clinician Knowledge of Anterior Cruciate Ligament Reconstruction Rehabilitation Practices: A Preliminary Survey Study

CONTEXT

After completing rehabilitation, patients face a high risk of subsequent injury following anterior cruciate ligament reconstruction. It is important to identify potential barriers to patient success including clinician knowledge. The purpose of this study was to assess clinician knowledge of research related to anterior cruciate ligament reconstruction rehabilitation.

DESIGN

This was a survey study using snowball sampling.

METHODS

Survey development began with the creation of a construct map and contained varying levels of advanced concepts, level I indicating the most basic and level V the most complex. The survey was distributed to advertise to target population. A total of 60 participants (24 athletic trainers, 33 physical therapists, and 3 dual credentialed) completed the study.

RESULTS

Overall, participants displayed moderate to high levels of knowledge (79.7%-93.5% correct), apart from the implementation of motor learning principles.

CONCLUSIONS

Clinician knowledge may not be the primary barrier to patient success, but the implementation of this knowledge should be explored in relation to patient outcomes. Future research should examine a larger cohort to examine differences between clinician types.

Impact of Functional Training on Injuries After Anterior Cruciate Ligament Reconstruction for Return-to-Duty Status in U.S. Naval Academy Midshipmen: A Retrospective Analysis

INTRODUCTION

Acute anterior cruciate ligament (ACL) injuries can be disabling because of prolonged rehabilitation process following surgical reconstructions. Rates of ACL injuries among military service members are close to 10 times greater than the general civilian population, likely because of the operation tempo and the unique physical requirements. Studies debated functional testing requirements for return to sports, but no study investigated the impact of functional training and re-injury rates following ACL reconstruction and their association with functional testing outcomes and time to return to full duty in United States Naval Academy (USNA) Midshipmen. Therefore, the purpose of this study was to review all ACL reconstructions with and without meniscal injury at USNA, the functional training and testing, timing of return to military training, and associations with postoperative re-injury rates.

MATERIALS AND METHODS

A retrospective chart review of all Midshipmen who sustained ACL reconstructions between 2015 and 2019 was performed. Demographic variables, type of surgeries, functional training/testing outcomes, timing to return to full duty and postoperative re-injury rates were recorded up to January 1, 2022.

RESULTS

Of 204 ACL reconstructions, 87 were excluded, resulting in a sample size of 117 including 76 (65%) men and 41 (35%) women aged 20.4 ± 1.4 years. Fifty-one (44%) Midshipmen sustained a re-injury to the postoperative knee or complication. Thirty-three out of 76 (43%) men and 18 out of 41 (35%) women sustained complication or re-injury to the surgical knee. Of those re-injuries or complications, 12 Midshipmen (10%) sustained graft failures,12 (10%) anterior arthrofibrosis, 7 (6%) meniscus tears, 17 (15%) patella tendinopathy, and 3% other ligament injuries (MCL, PCL, etc.). Fifty participants (43%) followed a functional training program while 67 (57%) lacked documented functional training. There was a significant difference in Midshipmen who participated in functional training, displaying fewer postoperative anterior cruciate ligament reconstruction (ACLR) re-injuries or complications to the surgical knee as compared to those who did not (0.027). Nineteen Midshipmen (16%) performed functional testing while 98 did not. Of the 98 Midshipmen who did not perform functional testing, 57 (58%) had re-injury or complications to the surgical knee postoperatively compared to 9 (48%) who performed functional testing sustained a re-injury or complication. The average return to full duty was 37.1 ± 25.8 weeks versus 63.8 ± 35.8 weeks for Midshipmen who sustained postoperative injuries. Within 1 year of return to duty, 6 of 12 (50%) ACL graft failures occurred.

DISCUSSION-CONCLUSION

Postoperative injuries and complications following ACLR can delay the ability to return to duty by twice as long, consequently effecting military manpower capability. A functional training and testing program resembling both an athletic and military/operational environment can reduce re-injury and complication rates, resulting in faster return-to-duty rates. Future studies should assess the impact of military rehabilitation participation following ACLR and functional testing protocols to assess physical readiness of Midshipmen to return to full duty. Additionally, methods to assess psychological readiness to return to duty should be further investigated.

Comparison of different pain management strategies during the perioperative period of esophageal squamous cell carcinoma: a retrospective cohort study

OBJECTIVE

This retrospective cohort study aims to evaluate and compare different postoperative pain management strategies for esophageal squamous cell carcinoma (ESCC), in order to provide scientific evidence for clinical practice and decision-making.

METHODS

A total of 274 ESCC patients who underwent surgery at the Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University were included in the study. Of these, 127 received conventional nursing decisions for postoperative pain management, and 147 received the "5 + nursing" postoperative pain management strategy. The main observation indicators of both groups included postoperative pain score, analgesic dosage, postoperative analgesic side effects, and length of hospital stays.

RESULTS

The "5 + nursing" postoperative pain management group showed significantly lower postoperative pain score and significantly shorter length of hospital stays than the conventional nursing group. There was no significant difference in postoperative analgesic side effects between the two groups. Multiple logistic regression analysis showed that the postoperative pain score is an independent risk factor for predicting postoperative arrhythmias in ESCC patients. When the daily average dose of opioids used postoperatively was between 37.5 and 50 mg, the patient's postoperative pain score dropped the fastest.

CONCLUSION

The "5 + nursing" pain management strategy can effectively reduce the degree of postoperative pain and shorten the length of hospital stays, improving patient's quality of life. Our research emphasizes the importance of opioids in postoperative pain management, as well as the need for individualized perioperative pain management strategies.

Finding the needle in the haystack of isokinetic knee data: Random Forest modelling improves information about ACLR-related deficiencies

The difficulties of rehabilitation after anterior cruciate ligament (ACL) injuries, subsequent return-to-sport (RTS) let alone achieving pre-injury performance, are well known. Isokinetic testing is often used to assess strength capacities during that process. The aim of the present machine learning (ML) approach was to examine which isokinetic data differentiates athletes post ACL reconstruction (ACLR) and healthy controls. Two Random Forest models were trained from data of unilateral concentric and eccentric knee flexor and extensor tests (30°/s, 150°/s) of 366 male (63 post ACLR) as well as 183 female (72 post ACLR) athletes. Via a cross-validation predictive performance was evaluated and the Random Forest showed outstanding results for male (AUC = 0.90, sensitivity = 0.76, specificity = 0.88) and female (AUC = 0.92, sensitivity = 0.85, specificity = 0.89) athletes. The Accumulated Local Effects plot was used to determine the impact of single features on the predictive likelihood. For both male and female athletes, the ten most impactful features either referred to the disadvantageous (injured, non-dominant in control group) leg or to lateral differences. The eccentric hamstring work at 150°/s was identified as the most impactful single parameter. We see potential for improving the RTS process by incorporating and combining measures, which focus on hamstring strength, leg symmetry and contractional work.

Hop to It! A Systematic Review and Longitudinal Meta-analysis of Hop Performance After ACL Reconstruction

BACKGROUND

Hop testing is widely used by clinicians to monitor rehabilitation and decide when to return to sport following anterior cruciate ligament reconstruction (ACLR); however, the trajectory of long-term hop performance has not been summarised.

OBJECTIVE

To investigate hop performance change over time after ACLR.

DESIGN

Systematic review with longitudinal meta-analysis.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, Scopus, Cochrane CENTRAL and SPORTDiscus to 28 February 2023.

ELIGIBILITY CRITERIA

Studies with ≥ 50 participants following primary ACLR, with mean participant age of 18-40 years, reporting a quantitative measure of hop performance (e.g. single forward hop distance). Results had to be reported for the ACLR limb and compared with (1) the contralateral limb (within person) and/or (2) an uninjured control limb (between person).

RESULTS

We included 136 studies of 23,360 participants. Performance was similar across different hop tests, with steep initial improvements in within-person symmetry, tailing off after 18-24 months. ACLR limb hop performance was 5-10% lower compared with the contralateral limb at 1 year post-surgery, with largest deficits observed for vertical hop [87.0% contralateral limb (95% CI 85.3-88.8) compared with single forward hop 93.8% (95% CI 92.8-94.9)]. By 3-5 years, results were similar between ACLR and contralateral limbs. There were limited data for between-person comparisons (n = 17 studies). Exploratory analyses showed deficits in all forward hopping tests to be very strongly correlated with each other [e.g. single forward and triple hop rho = 0.96 (95% CI 0.90-0.99)], though there was discordance in the relationship between single forward hop and vertical hop performance [rho = 0.27 (95% CI - 0.53 to 0.79)].

CONCLUSIONS

Hop performance is comparable to the uninjured limb by 3-5 years post-ACLR, with the greatest deficits in within-person symmetry present in vertical and side hop tests. Assessment of hopping in multiple planes and comparison with uninjured controls, may provide the most complete evaluation of functional performance.