Return-to-sport testing following ACL reconstruction revisited

Unilateral tests of lower-limb function as prognostic indicators of future knee-related outcomes following anterior cruciate ligament injury: a systematic review and meta-analysis of 13 150 adolescents and adults

OBJECTIVE

To investigate the prognostic capacity of individual hop tests, hop test batteries and other unilateral functional performance tests following anterior cruciate ligament (ACL) injury.

DESIGN

Systematic review with meta-analysis.

DATA SOURCES

Six databases searched up to June 2021.

ELIGIBILITY CRITERIA

Studies reporting associations between unilateral lower-limb function (eg, hop tests) following ACL injury and future (≥3 months) knee-related outcomes.

RESULTS

Of 42 included studies (13 150 participants), all assessed the single-forward hop test and 32 assessed a repeated-forward hop test (crossover hop, triple hop, 6m-timed hop), mostly within a year after ACL injury/reconstruction. Results of meta-analyses indicated that higher single-forward and repeated-forward hop limb symmetry were associated with higher odds of return-to-sport 1-3 years post-ACL reconstruction (OR 2.15; 95% CI 1.30 to 3.54; OR 2.11; 95% CI 1.23 to 3.60, respectively). Higher single-forward and repeated-forward hop limb symmetry was associated with better self-reported symptoms and function 1-37 years after ACL injury (OR 2.51; 95% CI 1.62 to 3.88; OR 4.28; 95% CI 1.65 to 11.08, respectively). Higher limb symmetry on a repeated-forward hop does not appear to be associated with higher odds of successful rehabilitation without ACL reconstruction (OR 1.51; 95% CI 0.94 to 2.44). Achieving ≥90% limb symmetry on the single-forward hop was associated with reduced odds of knee osteoarthritis 5-37 years after ACL injury (OR 0.46; 95% CI 0.23 to 0.94).

CONCLUSION

Very low certainty evidence suggests single-forward and repeated-forward hop tests are prognostic indicators for important knee-related outcomes in individuals after ACL injury and may help stratify individuals at risk of poor outcomes to target rehabilitation interventions.

PROSPERO REGISTRATION NUMBER

CRD42018092197.

Inclusion of a Military-specific, Virtual Reality-based Rehabilitation Intervention Improved Measured Function, but Not Perceived Function, in Individuals with Lower Limb Trauma

INTRODUCTION

Lower extremity injury is common in the military and can lead to instability, pain, and decreased function. Military service also places high physical demands on service members (SMs). Standard treatment interventions often fail to align with these unique demands. Thus, the goal of the study was to evaluate the effectiveness of a military-specific virtual reality-based rehabilitation (VR) intervention supplemental to standard care (SC) in improving military performance in SMs with lower extremity injuries.

MATERIALS AND METHODS

As part of an institutional review board-approved randomized control trial, SMs receiving care at an advanced rehabilitation center were randomized to receive either SC or VR in addition to SC (VR+SC). Participants were evaluated before treatment and ∼3 weeks later using a previously developed and validated military-specific assessment. Perceived improvement in physical function was measured using a Global Rating of Change (GROC) questionnaire. A repeated measures ANOVA was used to evaluate the effects of adding VR on the military-specific assessment measures. Linear regression was used to determine the relationship between perceived improvement, measured improvement, and VR volume.

RESULTS

The VR+SC group was able to traverse a greater distance in the assessment following the VR intervention. There was no significant difference in GROC between groups. For the VR+SC group, change in distance completed was not correlated with GROC, but GROC was correlated with VR volume.

CONCLUSION

VR improved the distance that participants were able to traverse in the assessment. However, the VR+SC group demonstrated a disconnect between their perceived functional improvement as measured by the GROC and functional improvement as measured by the change in the distance completed. Rather, the perceived improvement appears to be more correlated with the volume of VR received. The way in which the treatment progression is structured and communicated may influence how patients perceive their change in physical function.

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

Background:

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

Purpose:

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

Study Design:

Cohort study; Level of evidence, 2.

Methods:

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

Results:

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

Conclusion:

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