When Is It Safe to Return to Sport After ACL Reconstruction? Reviewing the Criteria

Anterior Cruciate Ligament Tears among Football Players

PURPOSE OF REVIEW

Anterior Cruciate Ligament (ACL) tears are one of the most common causes of lost playing time in American football athletes. Recently, there has been a push to get athletes back to sport faster. As such, numerous studies have evaluated management and rehabilitation protocols for return to play after ACL injury in football players. The purpose of this review is to synthesize information, both classic and new, to aid orthopedic surgeons in treatment of football players with ACL injuries.

RECENT FINDINGS

Recent studies have demonstrated that not all ACL injuries are alike. Management should be a shared decision-making process between athlete and surgeon. Studies have demonstrated low failure rates when using bone-patellar tendon-bone (BTPB) autograft which is the most common graft utilized for elite football athletes. Outcomes are continually being evaluated by multicenter study groups such as the Multicenter Orthopaedic Outcome Network which has established a thorough rehabilitation protocol focusing on athlete milestones. ACL tears in the football athlete are common and challenging injuries. Treatment revolves around ACL reconstruction, most commonly with BTPB autograft. Post-operative rehabilitation is essential and should focus on objective criteria rather than time elapsed. Return to play criteria rely upon symptoms, athlete confidence, strength, and both functional and football specific testing. Return-to-play timelines are individualized for each football athlete but recent trends have highlighted a more delayed return of at least 7-9 months. Rate of returning to play varies from 63-82% and depends upon many factors including level of play and position.

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.

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-play criteria based on infrared thermography during anterior cruciate ligament rehabilitation in football players

Reconstruction of the anterior cruciate ligament (ACL) is associated with degenerative changes during the return-to-play (RTP) process. Infrared thermography, due to its usefulness in monitoring the state of tissues, could help establish physiological criteria for monitoring the knee joint. The aim of the study was to describe normative skin temperature (Tsk) asymmetry of the knee region of interest (knee ROI) from football players during the ACL RTP process. Thirty professional and semi-professional football players, both male and female, from three different European leagues (age: 26.84 ± 3.46 years; height: 1.83 ± 0.22 m; weight: 75.38 ± 5.92 kg) were evaluated using thermography during their RTP process. A linear mixed model was then developed in which Tsk asymmetry was the dependent variable. Sex and Day were included as predictor variables with fixed effects. Athlete was included as a random effect with (Model 1 and Model 2) and without (Model 3) interaction with Day. Model 2 was fitted with a random intercept and random independent slopes, and Model 3 was fitted with a random intercept and random dependent slopes. The results showed the estimates of the model in which both predictor variables were significant. The asymmetry decreased during the days after surgery (-0.01 per day after surgery). The results might help to establish an objective criterion based on infrared thermography for monitoring the rehabilitation stages in the RTP of football players during one year of evolution. The assessment of the thermal asymmetries of the knee ROI during the RTP established a Tsk progression criterion. Medical and technical staff could implement an infrared thermography tool for knee monitoring between RTP stages.

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.

Hop distance to body height ratio outperforms limb symmetry index in predicting second anterior cruciate ligament injury

PURPOSE

The ability of current return-to-sport (RTS) tests to predict second anterior cruciate ligament (ACL) injuries (ACLI) in athletes with a history of ACL reconstruction (ACLR) is unclear. This study aimed to prospectively assess the risk of a second ACLI by identifying the most significant deviation in hop test results in professional athletes after ACLR compared to healthy peers.

METHODS

A total of 30 professional athletes with a history of ACLR and 30 healthy professional athletes participated in this study. Participants performed 10 functional hop tests, and the subsequent limb symmetry index (LSI) was compared between the groups. After a 3-year follow-up, the re-injury rate was assessed among the ACLR group. Fourteen ACLR athletes who sustained a second ACLI were included and matched with 14 controls from the healthy group. The LSI and the hop distance to body height percentage (D/H) were compared between the groups.

RESULTS

Statistical analyses confirmed a significant decrease in LSI in the ACLR group compared to the healthy group in the triple hop for distance (p = .023). In re-injured ACLR athletes, seven different hop tests showed a significant decrease in the D/H index compared to the healthy controls. Meanwhile, for LSI, only the triple cross-over hop for distance (p = .045) showed a significant increase in the healthy group.

CONCLUSION

Before clearing athletes for RTS, assessing functional hop test results using the hop distance to body height ratio, aligned with normative data from healthy controls, could further enhance the prediction of reduced graft rupture risk.

LEVEL OF EVIDENCE

Level I.

Combined Anterior Cruciate Ligament and Anteromedial Oblique Ligament Reconstruction Using the Rectus Femoris Tendon: Description of Surgical Technique

We present a technique for combined anterior cruciate ligament and anteromedial oblique ligament reconstruction using the rectus femoris tendon graft. Anatomic anterior cruciate ligament reconstruction and anteromedial reinforcement are performed with a single rectus femoris graft. The rectus femoris tendon graft is harvested in a reproducible and minimally invasive approach. The surgical technique requires no special instruments and consists of 3 bone tunnels. Fixation is performed with interference screws.

Early versus delayed start of weight-bearing after arthroscopic anterior cruciate ligament reconstruction with hamstring tendons

BACKGROUND

The aim of this prospective randomized clinical study was to compare the clinical and second-look arthroscopic outcomes of early weight-bearing and delayed weight-bearing rehabilitation protocols following anterior cruciate ligament (ACL) reconstruction with hamstring tendons.

METHODS

This prospective study involved 90 patients who underwent ACL reconstruction with hamstring tendons. The patients were randomly assigned to either perform weight-bearing exercises at three weeks postoperatively (group A) or at one week postoperatively (group B). Evaluation of the patients was conducted at 3, 6, and 12 months postoperatively, focusing on knee range of motion, thigh circumference, and knee function assessed using the International Knee Documentation Committee (IKDC) form and Lysholm knee score. Graft evaluation was performed based on tension, tear, and synovial coverage via second-look arthroscopy at least one year after reconstruction.

RESULTS

Group B exhibited significantly greater knee extension and flexion angles at 3 and 6 months compared to group A. IKDC and Lysholm scores were significantly higher in group B at 3 and 6 months. Additionally, the difference in thigh circumference between groups A and B was smaller at all evaluation periods, indicating less muscle atrophy in group B. Furthermore, there was no significant difference in synovial coverage, graft tear, or tension between the two groups based on second-look arthroscopy findings.

CONCLUSIONS

This study demonstrates that an early weight-bearing protocol leads to faster recovery of knee joint function and muscle strength, facilitating a quicker return to sports activities. Additionally, there was no significant difference in graft morphology observed at second-look arthroscopy between the two groups at one year postoperative. Therefore, clinicians are encouraged to develop suitable early weight-bearing rehabilitation protocols for patients who have undergone ACL surgery.

Cross-sectional area on magnetic resonance images of the semitendinosus tendon is strongly related to the collagen fibril diameter

Purpose

Using a thin semitendinosus tendon as an autograft is a risk factor for poor clinical outcomes after anterior cruciate ligament reconstruction. Preoperative evaluation of the cross-sectional area of the semitendinosus tendon using magnetic resonance imaging is useful. However, studies comparing the cross-sectional area of the semitendinosus tendon on magnetic resonance imaging and the collagen fibril diameter of the semitendinosus tendon are lacking. We aimed to investigate the relationship between collagen fibril diameter and cross-sectional area of the semitendinosus tendon using magnetic resonance imaging.

Methods

We included 14 patients (24.5 ± 12.3 years) who underwent anterior cruciate or medial patellofemoral ligament reconstruction using the semitendinosus tendon. Samples not used to prepare autografts were used to evaluate the collagen fibril diameter. Transmission electron microscopy was used to measure several hundred short fibril diameters per sample. Magnetic resonance imaging (T2-weighted imaging) was used to assess the cross-sectional area of the semitendinosus tendon, measured 8 cm proximal to the tibial attachment. Spearman's rank correlation coefficients were determined for collagen fibril diameter and cross-sectional area of the semitendinosus tendon on magnetic resonance imaging, and the relationship between both parameters was evaluated.

Results

The collagen fibril diameter of the semitendinosus tendon was calculated from 10,279 fibrils. The correlation coefficient between the collagen fibril diameter and the cross-sectional area of the semitendinosus tendon was 0.821 (p < 0.001).

Conclusions

A strong positive correlation was observed between the collagen fibril diameter and cross-sectional area of the semitendinosus tendon. A small cross-sectional area on the magnetic resonance image of the semitendinosus tendon indicated a thin collagen fibril diameter, which may affect the mechanical strength of the autograft for anterior cruciate ligament reconstruction. The collagen fibril diameter can be predicted preoperatively by measuring the cross-sectional area of the semitendinosus tendon using magnetic resonance imaging.

Level of Evidence

Level IV.

The "11 to Perf Score", a Test for Professional Players Returning to Soccer After Anterior Cruciate Ligament Reconstruction

Rupture of the anterior cruciate ligament (ACL) is common among soccer players. Although there are no strict recommendations for the return to sport, more and more practitioners are having their patients perform isokinetic and even composite tests. However, these tests have not yet been shown to be predictive of re-injury, and are not specific to professional footballers. Objectives: The "11 to Perf" is a test designed to help professional footballers return to sport after ACL reconstruction. Its originality lies in its integration of soccer practice with specific tests. The aim of this article is to present the "11 to Perf" evaluation method. Methods: A prospective cohort study was conducted at the Centre National du Football (FIFA center) in Clairefontaine, including professional footballers who have undergone anterior cruciate ligament surgery and rehabilitation. Tests include clinical assessments, jumping, agility, psychological and isokinetic tests and match simulation. Conclusions: The "11 to Perf" is a composite test designed to assess the return to sport of professional footballers after ACL reconstruction. Its predictive capacity for recurrence should be assessed in the future.

Editorial Commentary: Anterior Cruciate Ligament Patients Must Be Provided With Both Motivation and Tools to Continue Physical Therapy, Supervised or Independently, Beyond the Early Recovery Phase

Given the current American health insurance environment, many patients do not access physical therapy in the mid and later stages of recovery from anterior cruciate ligament (ACL) reconstruction. This trend is well established in the literature and seems very unlikely to change in the future. While highly competitive athletes generally have year-round access to therapists and trainers to guide them through months of recovery, most patients recovering from ACL reconstruction are recreational athletes with jobs, families, and varying levels of insurance coverage. This trend is well established in the literature, and recent research shows a substantial drop-off in physical therapy participation after 3 months. There are many potential reasons for the decreased utilization, including limitations in physical therapy visits covered by insurance, patient improvement to levels of near-normal motion and gait, and participation fatigue. Thankfully, this may be one of the instances where the latest technologies such as artificial intelligence can be beneficial, and many studies have shown advantages of telehealth in the field of physical therapy. Most of all, surgeons must act as educators and provide our post-ACL reconstruction patients with motivation and tools to continue physical therapy, if not supervised, then independently, beyond the early recovery phase.

Verbal instructions for attentional focus influence the results of tests for return to sport after anterior cruciate ligament reconstruction

This cross-sectional study investigated the influence of attentional focus verbal instructions on test results for return to sport (RTS) after ACL-R. Sixty subjects (53 male and 7 female, age 27.52 ± 7.63 years, body mass 77.56 ± 12.41 kg, height 162.04 ± 43.90 cm, and surgery time 11.15 ± 4.55 months) were evaluated in the single hop test (SHT), 6 m timed hop test (6mTHT), and "T" agility test. Participants performed the tests following randomly determined verbal instructions that induced neutral focus (NF), internal focus (IF), and external focus (EF). EF increased hop distance in SHT compared to NF (p = 0.001, effect size = 0.57) and IF (p = 0.037, effect size = 0.57) and there was no difference between IF and NF (p = 0.418). In 6mTHT, NF and EF increase velocity compared to IF (p = 0.001, effect size = 0.49, p = 0.001, effect size = 0.49, respectively). In the "T" agility test, the NF increased velocity when compared to the EF (p = 0.001, effect size = 0.62) and the IF (p = 0.001, effect size = 0.62), without difference between IF and EF (p = 0.071). In summary, attentional focus in patients under ACL-R can influence hops and agility.

Do we need a guideline for all: a qualitative study on the experiences of male athletes following anterior cruciate ligament reconstruction

BACKGROUND

Considering the low rate of qualitative studies on athletes with anterior cruciate ligament reconstruction (ACLR), aiming to access in-depth data, we thought that the utilization of the qualitative method would allow us to collect the appropriate and sufficient data to yield novel findings and achieve sound conclusions. The study's aim was to investigate anterior cruciate ligament (ACL) injury experience processes in athletes who had undergone isolated ACLR, reveal the clinically related milestones, and highlight the necessary gaps.

METHODS

Semi-structured interview techniques, in-depth follow-up questions, and thematic analysis were used to explore the experiences of participants with isolated ACL injuries 1-3 years after surgical treatment. The study was conducted in the Orthopaedics and Traumatology outpatient clinic of the Adana City Training and Research Hospital and included 14 male athletes who had undergone isolated primary ACLR. The study group's demographic and qualitative data were collected in the first week of September 2023. The member checking process was completed in the third following week. A thematic analysis checklist was used to ensure the reliability of the thematic analysis. The Consolidated Criteria for Reporting of Qualitative Research (COREQ) guidelines were followed.

RESULTS

The experiences of 14 patients (22.78 ± 3.76 years, all males) were summarized into four themes that emerged from the data analysis process: 'The Distinctions in the Participants' Experiences Regarding the Moment of Injury,' 'Gathering Information about the ACL Injury,' 'Factors That Facilitate The Treatment Process and Reinforce Positive Experiences,' and 'Desperate Plight: Main Points of Patients' Negative Experiences.' Based on the main themes, there were 14 subthemes.

CONCLUSIONS

Our study revealed that varying perceptions of ACL injury presented by the participants, which were caused by all stakeholders, including themselves, the professional environment, family members, social network, and the healthcare staff, showed that the physical and psychological impacts of the injury were observed in different severity levels at each stage of the process. We believe that an extensive guide for athletes with ACL injuries that includes all components of well-being and displays the required details for the sports club/coach, family/companion, and physician.

Effective Prevention and Rehabilitation Strategies to Mitigate Non-Contact Anterior Cruciate Ligament Injuries: A Narrative Review

Non-contact anterior cruciate ligament injuries (NC-ACLs) represent a significant concern in sports medicine, particularly among athletes and physically active individuals. These injuries not only result in immediate functional impairment but also predispose individuals to long-term issues such as recurrent instability and early-onset osteoarthritis. This narrative review examines the biomechanical, neuromuscular, and environmental factors that contribute to the high incidence of NC-ACLs and evaluates the effectiveness of current prevention and rehabilitation strategies. The review identifies key risk factors, including improper landing mechanics, deficits in neuromuscular control, and muscle imbalances, which are pivotal in the etiology of NC-ACLs. Prevention programs that incorporate plyometric exercises, strength training, and neuromuscular education have shown efficacy in reducing injury rates. Rehabilitation protocols that emphasize a gradual return to sport, focusing on pain management, restoration of range of motion, and progressive strengthening, are critical for successful recovery and prevention of re-injury. The evidence suggests that an integrated approach, combining prevention and rehabilitation strategies tailored to the individual, is essential for minimizing NC-ACL risk and improving outcomes in affected populations.

Trends in Anterior Cruciate Ligament Reconstruction Techniques and Postoperative Care Among Leaders in the Field: A Survey of the Herodicus Society

Background

Despite a growing body of literature regarding anterior cruciate ligament reconstruction (ACLR), there remains a wide diversity in surgical technique and clinical practice across providers.

Purpose

To (1) describe current ACLR practice preferences among members of the Herodicus society and (2) determine whether these preferences are influenced by years in practice and overall surgical volume.

Study Design

Cross-sectional study.

Methods

A 24-question survey investigating surgeons' practices and preferred ACLR surgical techniques was sent via email to all active Herodicus Society members. Survey responses were subdivided by years of experience and overall ACLR annual case volume. Descriptive statistics were compiled and chi-square testing was utilized to determine the significance of experience and case volume on survey responses.

Results

Of the 113 invited Herodicus Society members who perform ACLR, 69 (61%) completed the survey. Respondents had a mean ± SD of 30.9 ± 9.8 years of experience in clinical practice and performed a mean of 96.0 ± 50.7 primary and 21.6 ± 16.9 revision ACLR annually. Of revision cases, 72.1% were performed using a single-stage technique. Mean frequency of graft usage by surgeon was bone-patellar tendon-bone autograft (58.6%), quadriceps autograft (14.6%), hamstring tendon autograft (14.0%), and allograft (11.8%). The plurality of surgeons responded that they used anterolateral augmentation "rarely" in primary ACLR (39.1%) and "sometimes" in revision ACLR (31.9%), with the majority performing lateral extra-articular tenodesis (66.7%) rather than anterolateral ligament reconstruction (14.5%). Most surgeons would not allow a 20-year-old football player to return before 7 months after ACLR (71.0%) but highly valued return-to-sports testing to determine readiness (94.2%). Higher volume surgeons performed single-stage revision ACLR at a significantly higher rate (79.8% vs 62.9%, P = .02) and significantly differed in return-to-sports criteria, with a greater proportion relying primarily on biometric testing (P = .01).

Conclusion

The survey demonstrated that, in the Herodicus Society, a wide range of preferences exist regarding ACLR surgical technique. Bone-patellar tendon-bone autograft is the most frequent primary ACLR graft choice. Most participants have not embraced newer techniques such as anterolateral or suture tape augmentation. Return to sports is generally not allowed before 7 months and heavily factors-in return-to-sports testing metrics, suggesting that purely time-based criteria for return to sports is not modern practice among elite sports medicine surgeons.

Practice Patterns and Return-to-Sports Timing of National Football League Head Team Physicians for ACL Reconstruction

Background

Previous surveys of the practice patterns for anterior cruciate ligament (ACL) reconstruction in collegiate and professional team physicians have shown bone-patellar tendon-bone (BPTB) autograft being the most common graft, with variable return-to-sports timing.

Purpose

To evaluate the current practice patterns and return-to-sports timing of National Football League (NFL) head team physicians for ACL reconstruction.

Study Design

Cross-sectional study.

Method

All 32 NFL head team orthopaedic surgeons were surveyed and asked their primary ACL graft preference, revision ACL graft preference, use of lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALL), use of suture brace augmentation, return-to-sport timing, and whether functional testing was utilized in determining readiness of return to play. The years of experience of the physician were also evaluated.

Results

All 32 head team physicians responded, with 31 (97%) using ipsilateral BPTB autograft in the primary setting and 1 using ipsilateral quadriceps autograft. In the revision setting, 24 (75%) physicians preferred a contralateral BPTB autograft, while 5 (16%) used an ipsilateral quadriceps autograft, 1 (3%) used a contralateral quadriceps autograft, and 2 (6%) used a BPTB allograft. One respondent (3%) used suture brace augmentation "most of the time" in the primary setting and always in the revision setting. No respondents utilized an ALL or LET in the primary setting and 2 (6%) respondents always performed an LET in revisions. Five others (16%) have performed at least 1 ALL or LET in an NFL athlete. Mean return to sports was at 9 months postoperatively, with no physicians allowing players to return before 7 months. All but 1 respondent used functional testing in return-to-sports decision-making.

Conclusion

All but 1 of the 32 NFL head team physicians used BPTB autograft in primary ACL reconstruction. The majority preferred contralateral BPTB autograft in revisions, with a few considering extra-articular procedures or suture bracing in addition. On average, head team physicians allowed players to return at 9 months postoperatively, with none allowing return before 7 months. Nearly all utilized functional testing to aid in return-to-play decision-making. These homogenous findings in this high-risk and public athletic cohort aid in patient education and clinical decision-making for best treatment of ACL injuries, particularly in contact athletes.

Preoperative Psychological Competitive Ability Is Associated With Emotional States Six Months After Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Prospective Study

Background Psychological state has been reported as one of the factors strongly related to a return to sports after anterior cruciate ligament (ACL) reconstruction. However, its relationship with the emotional state remains unclear. The aim of this study was to investigate whether patients who have undergone ACL reconstruction and have a higher preoperative psychological competitive ability have a better emotional status preoperatively and six months postoperatively. Methods Patients with a Tegner activity score of ≥6 who underwent ACL reconstruction between 2015 and 2020 were divided into two groups according to their grades on the Diagnostic Inventory of Psychological Competitive Ability for Athletes (DIPCA.3). The emotional states preoperatively and at six months postoperatively were assessed using the Profile of Mood States Second Edition (POMS2) and compared between the two groups. Furthermore, the possibility of returning to sports was compared between the groups based on participation in the entire practice at six months postoperatively. Results Eighty-four patients were included and divided into the high (DIPCA.3 grades ≥4, n = 23) and low (DIPCA.3 <4, n = 61) groups. Vigor-activity and friendliness were significantly higher in the high group than in the low group preoperatively. The difference was even greater at six months after ACL reconstruction. In addition, the high group showed significantly better results postoperatively for fatigue-inertia and total mood disturbance. Rates of return to sports did not differ significantly between the high and low groups (56.5% vs. 54.1%). Conclusions Those with a higher preoperative psychological competitive ability were in a positive emotional state preoperatively and six months after ACL reconstruction. However, the psychological competitive ability did not affect the rate of participation in the entire practice at six months postoperatively.

Evaluation of Lower Limb Asymmetry Index Based on the 30-Second Skater Squat Functional Test in Young Men

Introduction: Physical performance tests (PPTs) are used for the pre-season evaluation of athletes and to monitor and control the rehabilitation process. PPTs include single-leg jumps, single-leg squats, and balance tests. One of the physical fitness tests is the skater squat test. The 30 s skater squat functional test (SSFT) is used as one of the tests to assess fitness and symmetry in the lower limbs. The present study aimed to calculate and compare the asymmetry index using the 30 s skater squat functional test, the single-leg distance jump test, and the isometric measurement of knee joint extensor strength. Materials and Methods: The study examined 25 men aged 23 ± 3.17 years. The study used the 30 s SSFT, the single-leg long jump test (SLLJT), and an isometric dynamometer test to measure peak moment of force values for extensors of the knee using the JBA Zbigniew Staniak® measuring station ("JBA" Zb. Staniak, Poland). The statistical analysis of functional test results and iso-metric dynamometry results was based on correlation analysis. Results: There was a moderate correlation between 30 s SSFT and SLLJT (r = 0.540), and between SLLJT and measurements of peak moment of force of the knee joint extensors (r = 0.533). Conclusions: The asymmetry index calculated based on functional tests and peak moment of force of the knee extensors in a group of young men should not be used interchangeably. The asymmetry index calculated from the 30 s skater squat functional test detects greater differences in knee extensor strength than the ASI index calculated from the single-leg long jump test in a group of young male athletes. The practical significance of this study was that its results could play an important role in the training process and monitoring the return to sports after a possible injury.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery.

METHODS

A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index.

RESULTS

Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore.

CONCLUSIONS

Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients.

CLINICAL RELEVANCE

Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

ChatGPT Responses to Common Questions About Anterior Cruciate Ligament Reconstruction Are Frequently Satisfactory

PURPOSE

To evaluate ChatGPT responses to common questions patients have regarding anterior cruciate ligament (ACL) reconstruction.

METHODS

Ten frequently asked questions regarding ACL tears and ACL reconstruction were chosen from the frequently asked questions found on the websites of major institutions. These were presented to ChatGPT and responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."

RESULTS

Four responses were satisfactory, requiring minimal clarification, 3 were satisfactory, requiring moderate clarification, 2 were unsatisfactory, and 1 was excellent, requiring no clarification.

CONCLUSIONS

As hypothesized, ChatGPT provided generally accurate information to common questions around ACL reconstruction. Although clarification often was needed, responses were satisfactory for providing generalized information about ACL tears and ACL reconstruction.

CLINICAL RELEVANCE

ChatGPT is a promising avenue for patients to learn about general background information regarding ACL reconstruction, although questions specific to any planned operation need to be addressed directly with an orthopaedic provider.

Enhancing Return to Alpine Skiing: Integrating Perceptual-Motor-Cognitive Considerations in Testing and Progressions: A Clinical Commentary

Alpine skiing poses significant risks for anterior cruciate ligament (ACL) injury at both recreational and professional levels, which is compounded by high rates of re-injury. Despite the existence of return to sport (RTS) and return to snow protocols, the frequency of ACL re-injury has not been mitigated, raising doubts about protocol effectiveness. Current RTS protocols primarily focus on biomechanical and neuromuscular factors in isolation, neglecting the important perceptual-motor-cognitive changes associated with ACL injuries and the high cognitive demands of skiing. The purpose of this clinical commentary is to address the perceptual-motor-cognitive demands specific to alpine skiing, evaluate RTS testing for skiers, and propose updated standards for testing and return to snow progressions that incorporate these considerations.

Level of Evidence

5.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Objective Clinical Measurement Tools for Functional Evaluation of the Surgical Patient

Following knee surgery, clinicians have traditionally used visually rated or time-based assessments of lower extremity movement quality to measure surgical outcomes, plan rehabilitation interventions, and measure success. These methods of assessment are prone to error and do not fully capture a patient's inefficient movement patterns post surgery. Further, currently available systems which objectively measure kinematics during these tasks are expensive and unidimensional. For these reasons, recent research has called for the development of objective and low-cost precision rehabilitation tools to improve clinical measurement of movement tasks. The purpose of this article is to highlight two such tools and their applications to knee surgery. The systems highlighted within this article are the Mizzou Point-of-Care Assessment System (MPASS) and the Mizzou Knee Arthrometer Testing System (MKATS). MPASS has demonstrated high levels of agreement with the gold-standard Vicon system in measuring kinematics during sit-to-stand (R > 0.71), lateral step-down (intraclass correlation coefficient [ICC] > 0.55, apart from ankle flexion), and drop vertical jump tasks (ICC > 0.62), as well as gait (R > 0.87). MKATS has been used to quantify differences in tibiofemoral motion between groups during lateral step-down, step-up-and-over, and step-up/step-down tasks. Objective measurement of clinical tasks using portable and inexpensive instruments, such as the MPASS and MKATS, can help clinicians identify inefficient movement patterns and asymmetries which may damage and wear down supporting structures within the knee and throughout the kinetic chain causing pain and discomfort. Identifying these issues can help clinicians to plan interventions and measure their progress at a lower cost than currently available systems. The MPASS and MKATS are useful tools which have many applications to knee surgery.

Body Mass Index Between 15 and 30 Does Not Influence Patient-Reported Outcomes After Anterior Cruciate Ligament Surgery Using a 10-mm-Diameter Bone-Tendon-Bone Graft

Purpose

To investigate the relation between body mass index (BMI) and outcomes after anterior cruciate ligament reconstruction (ACLR) using 10-mm-diameter bone-patellar tendon-bone grafts.

Methods

In this retrospective study, the Surgical Outcome System was used to measure patient-reported outcomes before and after ACLR between 2015 and 2019. The inclusion criteria consisted on patients undergoing primary ACLR performed by the senior surgeon, with recorded age of 15 years or older and BMI of 15.0 to 30. The exclusion criteria included revisions, concomitant procedures, age younger than 15 years, and unknown BMI. Patients were divided into cohorts to evaluate the Marx Activity Rating Scale (MARS), Tegner, International Knee Documentation Committee (IKDC), and Lysholm scores at various time points from injury to 2 years postoperatively.

Results

A total of 137 patients (100 male and 37 female patients) with an average age of 33 years (95% confidence interval, 30.6-35.4 years) and average BMI of 23.58 (95% confidence interval, 23.1-24.0) were divided into those with a BMI of 15 to 23.4 (group A, n = 69) and those with a BMI of 23.5 to 30 (group B, n = 68). A significant difference in MARS scores was found between the BMI groups before treatment, with mean scores of 11.55 (group A) and 9.41 (group B) (P = .011), and Tegner scores showed significance at 2 years, with scores of 6.45 and 5.41 for groups A and B, respectively (P = .009). Daily function scores were all insignificant. Female patients exhibited no significant differences across any patient-reported outcome measures or time points. Contrarily, male patients showed a significant difference in pretreatment MARS scores (14.30 in group A vs 9.96 in group B, P = .011). Additionally, scores at 2 years depicted Tegner values of 7.40 in group A versus 5.30 in group B (P = .012) and IKDC values of 96.92 in group A versus 90.47 in group B (P = .048). All results for female and male patients aged 30 years or younger indicated no significance.

Conclusions

Regardless of patient age or sex, BMI is not significantly associated with patient-reported outcomes after ACLR using 10-mm-diameter bone-patellar tendon-bone grafts.

Level of Evidence

Level III, retrospective cohort study.

Evaluation of Strength and Functional Ability of Soccer Players Two Years After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study

OBJECTIVES

This study examines the strength and functional capacity of active soccer players two years post anterior cruciate ligament reconstruction (ACLR).

METHODS

Sixteen players, two years post ACLR, participated. Isokinetic tests assessed Peak Torque (PT) for concentric and eccentric contractions, along with conventional (H/Qconv) and functional (H/Qfunc) H/Q ratios at various angular velocities. Functional ability was gauged through hop tests. Paired-Samples T Test compared PT and hop test values, as well as H/Qconv and H/Qfunc ratios between involved and non-involved limbs. Limb symmetry was evaluated using the Limb Symmetry Index (LSI).

RESULTS

After two years, participants exhibited significant differences in concentric PT between limbs. The non-involved limb demonstrated superior performance at isokinetic speeds. Eccentrically, PT for knee extensors and flexors showed no significant disparities between the operated and non-operated limbs across all velocities tested. Most participants did not achieve LSI 90-110% for knee extensors and flexors. No noteworthy distinctions were observed in H/Qconv, H/Qfunc, and hop tests between limbs. The majority met LSI 90-110% in hop tests, except in the 30-second side hop (37%).

CONCLUSIONS

Two years post ACLR, soccer players still manifest strength and functional deficits, heightening the risk of injury.

Psychological Readiness to Return to Sport (RTS) and RTS Rates Are Similar in Patients After Either Bilateral or Unilateral Anterior Cruciate Ligament Reconstruction

Purpose

To compare psychological readiness to return to sport (RTS), RTS rate, level of return, and time to return between patients who underwent bilateral anterior cruciate ligament reconstruction (ACLR) and those who underwent unilateral ACLR.

Methods

The electronic medical record at a single academic medical center was queried for patients who underwent ACLR from January 2012 to May 2020. The inclusion criteria were skeletally mature patients who underwent either single or sequential bilateral ACLR and who had undergone either the primary ACLR or second contralateral ACLR at least 2 years earlier. Bilateral ACLRs were matched 1:3 to unilateral reconstructions based on age, sex, and body mass index. Psychological readiness to RTS was assessed using the validated ACL Return to Sport After Injury (ACL-RSI) scale. This, along with time to return and level of RTS, was compared between the 2 cohorts.

Results

In total, 170 patients were included, of whom 44 underwent bilateral ACLR and 132 underwent unilateral ACLR. At the time of the first surgical procedure, patients in the unilateral cohort were aged 28.8 ± 9.4 years and those in the bilateral cohort were aged 25.7 ± 9.8 years (P = .06). The average time difference between the first and second surgical procedures was 28.4 ± 22.3 months. There was no difference in psychological readiness to RTS (50.5 in bilateral cohort vs 48.1 in unilateral cohort, P = .66), RTS rate (78.0% in unilateral cohort vs 65.9% in bilateral cohort, P = .16), percentage of return to preinjury sport level (61.2% in unilateral cohort vs 69.0% in bilateral cohort, P = .21), or time to return (41.2 ± 29.3 weeks in unilateral cohort vs 35.2 ± 23.7 weeks in bilateral cohort, P = .31) between the 2 cohorts.

Conclusions

Compared with patients who undergo unilateral ACLR, patients who undergo bilateral ACLR are equally as psychologically ready to RTS, showing equal rates of RTS, time to return, and level of return.

Level of Evidence

Level III, retrospective cohort study.

Comparison of Revision ACL Reconstruction Using Iliotibial Band Augmented With Allograft Versus Bone-Patellar Tendon-Bone Autograft With Lateral Extra-articular Tenodesis

Background

Bone-patellar tendon-bone (BTB) anterior cruciate ligament reconstruction (ACLR) is one of the conventional techniques in the revision setting especially after a primary hamstring tendon graft. The use of the iliotibial band (ITB) augmented with allograft (AG) is an encouraging graft alternative for ACLR in terms of clinical and biomechanical data in the literature.

Purpose

To compare the clinical outcomes of BTB graft with lateral extra-articular tenodesis, modified Lemaire (BTB-LET), and an ITB graft augmented with hamstring AG (ITB-AG) in the setting of revision ACLR.

Study Design

Cohort study; Level of evidence, 3.

Methods

Descriptive data and clinical outcomes were prospectively collected from patients who underwent revision ACLR with either the BTB-LET or ITB-AG technique between 2012 and 2020 and who had a minimum follow-up of 2 years. The clinical outcomes were assessed by the Lysholm, Tegner, Anterior Cruciate Ligament-Return to Sport after Injury, International Knee Documentation Committee subjective knee evaluation form, and Knee injury and Osteoarthritis Outcome Score. Return to sports, complications, and revisions were also analyzed.

Results

A total of 167 patients were included, with 106 patients in the BTB-LET group and 61 patients in the ITB-AG group. There were no significant group differences in sociodemographic characteristics; however, the mean follow-up was significantly longer in the BTB-LET compared with the ITB-AG group (52.0 vs 38.8 months, respectively; P = .0001). There were no significant differences in postoperative outcome scores; however, patients in the ITB-AG group had a higher rate of return to competitive pivoting sports (32.8% vs 17.9%; P = .0288) and a higher overall rate of return to preinjury sport (63.9% vs 47.2%; P = .0365). Complications, including revisions for meniscal or chondral lesions and retears (8 [8.3%] in the BTB-LET group and 2 [4.0%] in the ITB-AG group), were not significantly different. All retears were due to sports-related accidents.

Conclusion

In this study, ITB-AG was not different from BTB-LET in terms of functional outcomes scores but allowed better return to sport rate. Performing ITB-AG reconstruction in the setting of revision ACLR appears to be safe, effective, and associated with a satisfying return-to-sports rate.

Limited preoperative knee extension in anterior cruciate ligament reconstruction using a hamstring tendon affects improvement of postoperative knee extensor strength

PURPOSE

This study aimed to determine the factors affecting knee extensor strength 6 months after anterior cruciate ligament (ACL) reconstruction using autograft hamstring tendon.

METHODS

144 patients who could undergo regular follow-up after ACL reconstruction were divided into 2 groups: those with greater than 90% (Group A: n = 95) and less than 85% (Group B: n = 49) isokinetic knee contraction at 60°/s 6 months post-ACL reconstruction. Basic information, injury status, limited preoperative knee extension, and knee extensor strength at 3 and 6 months postoperatively were compared between the groups. Multivariate logistic analysis was performed and included variables that showed statistically significant differences between the groups in the univariate analysis. In addition, the cut-off value for the limb symmetry index (LSI) at 3 months postoperatively needed to exceed an LSI of 90% at 6 months postoperatively was calculated using the receiver operating characteristics curve.

RESULTS

Age, preoperative waiting period, limited preoperative knee extension, and knee extensor strength at 3 months postoperatively were significantly different between the two groups. The multivariate logistic analysis showed that all the variables affected the improvement in knee extensor strength at 6 months postoperatively. Limited preoperative knee extension was the most significant factor (odds ratio: 15.1, 95% confidence interval: 2.57-118.56, p < 0.01). The LSI cut-off value at 3 months postoperatively was 72.0%.

CONCLUSION

Key factors in achieving the necessary knee extensor strength criteria for return to sports at 6 months post-ACL reconstruction include addressing limited preoperative knee extension and achieving an LSI ≥ 72% in knee extensor strength at 3 months postoperatively.

LEVEL OF EVIDENCE

Level III.

Greater self-efficacy, psychological readiness and return to sport amongst paediatric patients compared with adolescents and young adults, 8 and 12 months after ACL reconstruction

PURPOSE

The purpose of this study was to evaluate differences in rehabilitation-specific outcomes between paediatric patients, adolescents and young adults within the first 2 years after anterior cruciate ligament (ACL) reconstruction. A further aim was to determine whether patient age was associated with an increased risk of not achieving symmetrical muscle function within the first 2 years after ACL reconstruction.

METHODS

The patient data in the present study were extracted from the rehabilitation outcome registry, Project ACL. Patients aged 11-25 years registered for primary ACL reconstruction with a hamstring tendon autograft between April 1, 2013 and November 23, 2020 were included. A total of 691 patients met the inclusion criteria and were included in the study; 41 paediatric patients (females 11-13, males 11-15 years), 347 adolescents (females 14-19, males 16-19 years) and 303 young adults (females 20-25, males 20-25 years).

RESULTS

The comparison between groups revealed that 70% of paediatric patients, 39% of adolescents and 35% of young adults had returned to knee-strenuous sport at 8 months and that 90% of paediatric patients, 71% of adolescents and 62% of young adults had returned to sport at 12 months. Paediatric patients also reported higher scores compared with both the other patient groups on the Knee Self-Efficacy Scale (K-SES) and the Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI) at 8 and 12 months.

CONCLUSIONS

A larger proportion of paediatric patients had returned to sport compared with adolescents and young adults 8 and 12 months after ACL reconstruction. Paediatric patients also reported higher self-efficacy and greater psychological readiness to return to sport at 8 and 12 months than the other two groups. No differences in terms of muscle function tests when comparing paediatric patients, adolescents and young adults were found.

LEVEL OF EVIDENCE

II.

Effects of a Perioperative Blood Flow Restriction Therapy Program on Early Quadriceps Strength and Patient-Reported Outcomes After Anterior Cruciate Ligament Reconstruction

Background

Quadriceps muscle atrophy remains a limiting factor in returning to activity after anterior cruciate ligament reconstruction (ACLR). Blood flow restriction (BFR) therapy may accelerate quadriceps strengthening in the perioperative period.

Purpose

To evaluate postoperative isometric quadriceps strength in patients who underwent ACLR with a perioperative BFR program.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Patients indicated for ACLR were randomized into 2 groups, BFR and control, at their initial clinic visit. All patients underwent 2 weeks of prehabilitation preoperatively, with the BFR group performing exercises with a pneumatic cuff set to 80% limb occlusion pressure placed over the proximal thigh. All patients also underwent a standardized postoperative 12-week physical therapy protocol, with the BFR group using pneumatic cuffs during exercise. Quadriceps strength was measured as peak and mean torque during seated leg extension and presented as quadriceps index (percentage vs healthy limb). Patient-reported outcomes (PROs), knee range of motion, and quadriceps circumference were also gathered at 6 weeks, 3 months, and 6 months postoperatively, and adverse effects were recorded.

Results

Included were 46 patients, 22 in the BFR group (mean age, 25.4 ± 10.6 years) and 24 in the control group (mean age, 27.5 ± 12.0 years). At 6 weeks postoperatively, the BFR group demonstrated significantly greater strength compared with the controls (quadriceps index: 57% ± 24% vs 40% ± 18%; P = .029), and the BFR group had significantly better Patient-Reported Outcomes Measurement Information System-Physical Function (42.69 ± 5.64 vs 39.20 ± 5.51; P = .001) and International Knee Documentation Committee (58.22 ± 7.64 vs 47.05 ± 13.50; P = .011) scores. At 6 weeks postoperatively, controls demonstrated a significant drop in the peak torque generation of the operative versus nonoperative leg. There were no significant differences in strength or PROs at 3 or 6 months postoperatively. Three patients elected to drop out of the BFR group secondary to cuff intolerance during exercise; otherwise, no other severe adverse events were reported.

Conclusion

Integrating BFR into perioperative physical therapy protocols led to improved strength and increased PROs at 6 weeks after ACLR. No differences in strength or PROs were found at 3 and 6 months between the 2 groups.

Registration

NCT04374968 (ClinicalTrials.gov identifier).

Indications for Surgery, Activities After Surgery, and Pain Are the Most Commonly Asked Questions in Anterior Cruciate Ligament Injury and Reconstruction

Purpose

To leverage Google's search algorithms to summarize the most commonly asked questions regarding anterior cruciate ligament (ACL) injuries and surgery.

Methods

Six terms related to ACL tear and/or surgery were searched on a clean-installed Google Chrome browser. The list of questions and their associated websites on the Google search page were extracted after multiple search iterations performed in January of 2022. Questions and websites were categorized according to Rothwell's criteria. The Journal of the American Medical Association (JAMA) Benchmark criteria were used to grade website quality and transparency. Descriptive statistics were provided. χ2 and Student t-tests identified for categorical differences and differences in JAMA score, respectively (significance set at P < .05).

Results

A total of 273 unique questions associated with 204 websites were identified. The most frequently asked questions involved Indications/Management (20.2%), Specific Activities (15.8%), and Pain (10.3%). The most common websites were Medical Practice (27.9%), Academic (23.5%), and Commercial (19.5%). In Academic websites, questions regarding Specific Activities were seldom included (4.7%) whereas questions regarding Pain were frequently addressed (39.3%, P = .027). Although average JAMA score was relatively high for Academic websites, the average combined score for medical and governmental websites was lower (P < .001) than nonmedical websites.

Conclusions

The most searched questions on Google regarding ACL tears or surgery related to indications for surgery, pain, and activities postoperatively. Health information resources stemmed from Medical Practice (27.9%) followed by Academic (23.5%) and Commercial (19.5%) websites. Medical websites had lower JAMA quality scores compared with nonmedical websites.

Clinical Relevance

These findings presented may assist physicians in addressing the most frequently searched questions while also guiding their patients to greater-quality resources regarding ACL injuries and surgery.

Alterations of energy expenditure after anterior cruciate ligament tear and reconstruction. A systematic review

Background

The ever-increasing sport level makes every single detail of the athlete's cardiorespiratory profile count, and therefore, it is deemed crucial to clarify how the anterior cruciate ligament (ACL) reconstruction (ACLR) affects the energy economy of an athlete compared to the ACL-deficient and healthy subjects. The purpose of this review was to systematically analyze the studies investigating the correlation between the energy-oxygen cost in patients following ACLR in unreconstructed and intact ACLs.

Methods

We conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. PubMed, Cochrane, and Google Scholar databases were searched, and eight articles describing miscellaneous methods for the assessment of oxygen consumption in patients with ACL deficiency or ACL reconstructed knees were included.

Results

In total, 285 subjects were recorded with a mean age of 29.61 years. The type of exercise the patients were subjected to varied among the studies, including one-leg cycling, exercise in the closed kinetic chain, walking, jogging, or running at various speeds, and treadmill inclinations. The energy expenditure of an ACL-deficient patient is considerably higher than a healthy subject. Additionally, chronicity of the ACL tear is not correlated with energy expenditure. ACL deficiency leads to higher energy consumption, not only during walking but during jogging as well. ACLR could improve the efficiency of walking by lowering the energy demands. After ACLR, professional soccer players' aerobic capacity (VO2max) is improved significantly.

Conclusions

ACL insufficiency affects substantially the metabolic energy costs, resulting in increased energy expenditure. According to current literature, ACLR can help to partially reverse this condition, as significant improvements and a more efficient, energy-wise, locomotion are expected. However, further research is necessary to clarify if ACLR can completely normalize energy expenditure again. HIPPOKRATIA 2023, 27 (4):119-125.

Qualitative Research in Return to Sport: a Current Review of the Literature

PURPOSE OF REVIEW

Return to sport (RTS) is an important metric tied to patient satisfaction after receiving treatment for a sports-related injury. Recently, there has been an explosion of literature on RTS; yet a comprehensive review encompassing multiple injuries does not exist. Furthermore, RTS has historically been defined by quantitative measures that assess strength, function, and pain but little consideration has been given to psychologic factors nor has there been an open-ended forum for athletes to share with health care providers which factors they feel are most influential for RTS. This review also serves to heighten surgeons' awareness of underlying psychologic/psychosocial factors affecting RTS.

RECENT FINDINGS

Qualitative studies which employ open-ended questioning of athletes who have undergone surgical management of superior labral anterior-posterior (SLAP) tears, shoulder instability, ulnar collateral ligament (UCL) rupture, femoral acetabular impingement (FAI), and anterior cruciate ligament (ACL) tear demonstrate that fear of reinjury, lack of social support, and unrealistic expectations are all barriers to RTS. Qualitative studies give health care providers unique insight into the perspectives of their patients so that unmet postoperative needs can be addressed to facilitate RTS. Sports psychologists, coaches, athletic trainers, and physical therapists should create a positive environment to address these needs and provide optimal, holistic care to return athletes to the field safely. Though time consuming, further qualitative research is necessary to understand the unique factors affecting RTS in athletes.

Call for the application of a biopsychosocial and interdisciplinary approach to the return-to-sport framework of snow sports athletes

Snow sports such as alpine skiing or snowboarding are associated with a high risk of injury and reinjury and are subject to a very special environment with specific rehabilitation challenges that must be addressed. Due to geographic decentralisation, seasonal climatic limitations, alternation of training in off-snow and on-snow settings and unique loading patterns of practising these sports, special rehabilitation structures and processes are required compared with other sports. In addition, returning to preinjury performance requires a high level of confidence and a resumption of risk-taking in demanding situations such as high-speed skiing and high-amplitude jumps. A biopsychosocial and interdisciplinary approach can be viewed as a holistic, athlete-centred approach that promotes interprofessional communication and collaboration. This is particularly central for managing the physical/biological, psychological and social demands of injury management for snow sports. It can help ensure that rehabilitation content is well coordinated and tailored to individual needs. This is because transitions between different rehabilitation phases and caring professionals are well aligned, and rehabilitation is understood not only as purely 'physical recovery' but also as 'psychological recovery' considering the snow sports-specific setting with specific social norms. Ultimately, this may improve the rehabilitation success of snow sports athletes.

Lower rates of return to sport in patients with generalised joint hypermobility two years after ACL reconstruction: a prospective cohort study

BACKGROUND

Generalised joint hypermobility (GJH) has been associated with an increased risk of suffering an anterior cruciate ligament (ACL) injury. Patients with GJH exhibit lower muscle strength and poorer scores for patient-reported outcomes after ACL reconstruction, compared with patients without GJH. The aim of this study was to examine differences in the percentages of patients who return to sport (RTS) or pre-injury level of activity (RTP), muscle function and patient-reported outcomes at the time of RTS or RTP, as well as the time of RTS or RTP in patients with GJH compared with patients without GJH in the first two years after ACL reconstruction.

METHODS

This prospective study used data from an ACL- and rehabilitation-specific register located in Gothenburg, Sweden. Patients aged between 16 and 50, who had a primary ACL injury treated with reconstruction, were included. Data up to two years after ACL reconstruction were used and consisted of achieving RTS and RTP, results from isokinetic muscle function tests for knee extension and flexion and patient-reported outcomes (Knee Self-Efficacy Scale, Knee injury and Osteoarthritis Outcome Score and ACL-Return to Sport after Injury scale) at the time of RTS, as well as the time of RTP. A Beighton Score of ≥ 5/9 was used to define GJH. A Tegner Activity Scale of ≥ 6 was used to define RTS, while a Tegner equal to or above pre-injury level was used to define RTP.

RESULTS

A total of 1,198 patients (54.7% women) with a mean age of 28.5 ± 8.6 years were included. A smaller proportion of patients with GJH achieved RTS compared with patients without GJH (49.2% vs. 57.3%, Odds ratio: 0.720, p = 0.041). Furthermore, patients with GJH were marginally less symmetrical on the knee extension strength test, expressed as a Limb Symmetry Index, at the time of RTP compared with patients without GJH (87.3 ± 13.5 vs. 91.7 ± 14.3, Cohen's d = 0.142, p = 0.022). No further differences were found between groups regarding any muscle function tests or patient-reported outcomes.

CONCLUSION

A smaller proportion of patients with GJH achieved RTS compared with patients without GJH. Patients with GJH displayed less symmetrical knee extension strength at the time of RTP compared with patients without GJH.

Anterior Cruciate Ligament Return to Play: Where Are We Now?

Anterior cruciate ligament reconstruction (ACLR) is a commonly performed orthopaedic procedure, and it is crucial to assess an athlete's readiness to safely return to sports following ACLR to minimize the risk of reinjury. Despite this, determining optimal return to play (RTP) criteria following ACLR that is accurate, accessible, and reproducible remains challenging. This review aims to discuss commonly employed RTP criteria domains, including functional assessments, patient-reported outcomes, and psychological tests, as well as emerging technologies such as magnetic resonance imaging (MRI) that may play a role as a gold standard in RTP assessment. The findings of this review suggest RTP decision making after ACL surgery is nuanced and traditionally used objective measures do not perfectly predict RTS rates or clinical outcomes. In the future, a standardized MRI screening tool could help predict reinjury. The role of functional and psychological patient-reported outcome measures needs to defined, and objective criteria should be rigorously evaluated for whether they accurately screen an athlete's physical readiness and should be expanded to include more sport-specific movement analysis.

[Return to Sport (RTS) After Anterior Cruciate Ligament Reconstruction: Which Factors Influence the RTS Decision?]

BACKGROUND

It is unknown which valid criteria should be considered to justify the decision for return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR). The research question is whether gender, age, the outcome of the isokinetic maximal strength measurement and the single-leg hop test (quantitative/qualitative) influence the decision for RTS nine months after ACLR.

METHODS

This study is a retrospective data analysis. The research question was evaluated with a multiple logistic regression analysis (MLR). The dependent variable, RTS yes/no, is based on the decision of the orthopaedist in charge of treatment nine months (±30 days) after ACLR. The following possible influencing factors were investigated: gender, age, limb symmetry index (LSI) of maximal knee extension and knee flexion strength at 60°/sec., LSI of single-leg hop test and evaluation of knee valgus.

RESULTS

Data of 71 patients were included for MLR. The odds ratios (OR) for RTS increased with female gender (OR, 4.808; p=0.035), a higher LSI of maximal strength of knee extension (OR, 1.117; p=0.009) and a higher LSI of the single-leg hop test (OR, 1.125; p=0.020). Age, the LSI of maximal strength of knee flexion and knee valgus had no influence on the RTS decision.

CONCLUSION

Gender and the limb symmetry indexes of the maximal strength of knee extension and of the single-leg hop test are associated with RTS nine months after ACLR. These results should be considered to optimise rehabilitation after ACLR.

The effects of weight bearing on muscle atrophy early after ACL reconstruction in rats

We examined the effects of weight bearing after anterior cruciate ligament (ACL) reconstruction on muscle atrophy in rats. Rats were divided into the following groups: untreated control, ACL reconstruction (amount of weight bearing was small), ACL reconstruction plus hindlimb unloading (nonweight bearing), and ACL reconstruction plus morphine administration (amount of weight bearing was large) groups. At 7 or 14 days after surgery, atrophy of the rectus femoris and gastrocnemius was assessed. ACL reconstruction induced muscle atrophy in the rectus femoris and gastrocnemius. Unloading facilitated atrophy in the gastrocnemius but not in the rectus femoris. Morphine administration partially prevented atrophy in the gastrocnemius but not in the rectus femoris. After ACL reconstruction, the gene expression of insulin-like growth factor-1 (IGF-1), which is involved in protein synthesis, was downregulated in the gastrocnemius. Unloading decreased the gene expression of IGF-1 and increased the gene expression of atrogin-1, which is involved in protein breakdown, in the gastrocnemius. Morphine administration attenuated the downregulation of IGF-1. Atrophy of the gastrocnemius was more severe with a decrease in weight bearing, although the effect of weight bearing on rectus femoris atrophy was limited in rats. Early weight bearing is effective for reducing gastrocnemius muscle atrophy after ACL reconstruction.

Effect of Age and Sex on Psychological Readiness and Patient-Reported Outcomes 6 Months After Primary ACL Reconstruction

Background

Successful return to sport after anterior cruciate ligament (ACL) reconstruction (ACLR) can be affected by a patient's physical and psychological state throughout the rehabilitation process.

Purpose

To prospectively compare differences in patients at 6 months after primary ACLR with the ACL-Return to Sport after Injury (ACL-RSI), International Knee Documentation Committee (IKDC) or pediatric (Pedi)-IKDC, Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS), and Patient-Reported Outcomes Measurement Information System-Psychological Stress Experiences (PROMIS-PSE) scores.

Study Design

Prospective cohort study; Level of evidence, 2.

Methods

Patients enrolled were 8 to 35 years old who underwent primary ACLR and had their 6-month follow-up appointments between December 2018 and March 2020. Patients were divided into 3 age groups as follows: (1) preadolescents (10-14 years); (2) adolescents (15-18 years); and (3) adults (>18 years). Outcomes on the ACL-RSI, IKDC/Pedi-IKDC, Pedi-FABS, and PROMIS-PSE were compared according to age group, graft type (hamstring, patellar tendon, quadriceps, or iliotibial band autograft), and sex.

Results

A total of 176 patients (69 male, 107 female), with a mean age of 17.1 ± 3.1 years were included in the study. The mean ACL-RSI scores were significantly different among age groups (preadolescents, 75 ± 18.9; adolescents, 61.5 ± 20.4; and adults, 52.5 ± 19.8 [P < .001]) and graft types (P = .024). The IKDC and PROMIS-PSE scores were also significantly different among age groups (P < .001 and P = .044, respectively) and graft types (P = .034 and P < .001, respectively), with the iliotibial graft and the younger age group performing the best. There was no significant difference in the Pedi-FABS either by age group (P = .127) or graft type (P = .198). Female patients had lower ACL-RSI scores and higher (worse) scores on PROMIS-PSE than their male counterparts (P = .019 and P < .001, respectively), with no sex-based differences on IKDC or Pedi-FABS scores. The ACL-RSI and IKDC were positively correlated (Spearman r = 0.57; P < .001), while the ACL-RSI and PROMIS-PSE were negatively correlated (Pearson r = -0.34; P < .001).

Conclusion

This study suggests that psychological profiles and subjective perceptions of knee function 6 months after ACLR may vary in patients of different ages and between the sexes. Preadolescent patients had better scores on a majority of patient-reported outcomes compared with adolescent and adult patients.

Missing The Forest For The Trees: A Lack Of Upper Extremity Physical Performance Testing In Sports Physical Therapy

Background

Despite shoulder and elbow injuries being common in athletics, return to sport and reinjury rates are less than ideal. These outcomes may be driven by the absence of evidence-informed testing to determine an athlete's readiness for sport.

Purpose

The purpose of this study was to explore the reported frequency of physical performance testing for return to sport readiness by physical therapists treating athletes with upper extremity injuries and to identify potential barriers that may limit use of these tests. A secondary aim was to compare practice patterns of clinicians with sports physical therapy specialty certification to clinicians without.

Study Design

International, cross-sectional survey using purposive sampling.

Methods

A survey instrument was created to assess the frequency of use of physical performance tests by physical therapists treating athletes with upper extremity injuries, as well as the barriers limiting the use of these tests. The 19-question online survey was distributed via email and Twitter among sports physical therapists. Independent t-tests and Chi Square analyses were conducted to determine differences in practice patterns between physical therapists with and without specialization and the frequency of potential barriers that may limit the use of these tests.

Results

Four hundred ninety-eight participants met study eligibility and completed the survey. Fewer than half of participants reported using any physical performance test in making return to sport decisions for athletes with upper extremity injuries. The greatest barriers to the use of physical performance tests were a lack of equipment followed by lack of understanding of the literature, lack of time, and lack of supporting literature. Sports specialist clinicians were significantly more likely (p<0.001) to use physical performance tests than non-specialist clinicians (71.6% versus 36.3%).

Conclusion

In this survey of physical therapists (n=498), the majority admit to not using physical performance tests when making return to sport decisions for athletes with upper extremity injuries regardless of specialization.Physical therapists have an opportunity to improve the utilization physical performance testing in the upper extremity athlete in hopes of reducing injury recurrence and enhance return to sport rates.

Level of Evidence

Level 3b.

Graft-Specific Surgical and Rehabilitation Considerations for Anterior Cruciate Ligament Reconstruction with the Quadriceps Tendon Autograft

Anterior cruciate ligament reconstruction (ACLR) with a bone-patellar tendon-bone (BPTB) or hamstring tendon (HT) autograft has traditionally been the preferred surgical treatment for patients returning to Level 1 sports. More recently, international utilization of the quadriceps tendon (QT) autograft for primary and revision ACLR has increased in popularity. Recent literature suggests that ACLR with the QT may yield less donor site morbidity than the BPTB and better patient-reported outcomes than the HT. Additionally, anatomic and biomechanical studies have highlighted the robust properties of the QT itself, with superior levels of collagen density, length, size, and load-to-failure strength compared to the BPTB. Although previous literature has described rehabilitation considerations for the BPTB and HT autografts, there is less published with respect to the QT. Given the known impact of the various ACLR surgical techniques on postoperative rehabilitation, the purpose of this clinical commentary is to present the procedure-specific surgical and rehabilitation considerations for ACLR with the QT, as well as further highlight the need for procedure-specific rehabilitation strategies after ACLR by comparing the QT to the BPTB and HT autografts.

Level of Evidence

Level 5.

The combined effects of treadmill exercise and steroid administration on anterior cruciate ligament reconstruction-induced joint contracture and muscle atrophy in rats

Rehabilitation protocols to treat joint contracture and muscle atrophy following anterior cruciate ligament (ACL) reconstruction have not been established. In this study, we examined the combined effects of exercise therapy and steroid administration on joint contracture and muscle atrophy following ACL reconstruction. Rats received ACL transection and reconstructive surgery in one knee. After surgery, they were divided into four groups: no intervention, treadmill exercise (started from day three post-surgery, 12 m/min, 60 min/d, 6 d/week), treatment with the steroidal drug dexamethasone (250 μg/kg on days 0-5, 7, and 9 post-surgery), and dexamethasone treatment plus treadmill exercise. Age-matched untreated rats were used as controls. At day 10 or 30 post-surgery, we assessed ACL-reconstruction-induced joint contracture, joint capsule fibrosis, osteophyte formation, and muscle atrophy of the rectus femoris and gastrocnemius. Treadmill exercise after ACL reconstruction improved several indicators of muscle atrophy in both muscles, but it did not have positive effects on joint contracture. Dexamethasone treatment after ACL reconstruction improved joint contracture and joint capsule fibrosis at both timepoints and partially attenuated osteophyte formation at day 10 post-surgery, but delayed recovery from atrophy of the rectus femoris at day 30 post-surgery. The two treatments combined improved both joint contracture and atrophy of the rectus femoris and gastrocnemius. Exercise therapy combined with steroid administration may therefore be a novel therapeutic strategy for joint contracture and muscle atrophy following ACL reconstruction.

High-demand tasks show that ACL reconstruction is not the only factor in controlling range of tibial rotation: a preliminary investigation

BACKGROUND

Excessive range of tibial rotation (rTR) may be a reason why athletes cannot return to sports after ACL reconstruction (ACLR). After ACLR, rTR is smaller in reconstructed knees compared to contralateral knees when measured during low-to-moderate-demand tasks. This may not be representative of the amount of rotational laxity during sports activities. The purpose of this study is to determine whether rTR is increased after ACL injury compared to the contralateral knee and whether it returns to normal after ACLR when assessed during high-demand hoptests, with the contralateral knee as a reference.

METHODS

Ten ACL injured subjects were tested within three months after injury and one year after reconstruction. Kinematic motion analysis was conducted, analysing both knees. Subjects performed a level-walking task, a single-leg hop for distance and a side jump. A paired t-test was used to detect a difference between mean kinematic variables before and after ACL reconstruction, and between the ACL-affected knees and contralateral knees before and after reconstruction.

RESULTS

RTR was greater during high-demand tasks compared to low-demand tasks. Pre-operative, rTR was smaller in the ACL-deficient knees compared to the contralateral knees during all tests. After ACLR, a greater rTR was seen in ACL-reconstructed knees compared to pre-operative, but a smaller rTR compared to the contralateral knees, even during high-demand tasks.

CONCLUSION

The smaller rTR, compared to the contralateral knee, seen after a subacute ACL tear may be attributed to altered landing technique, neuromuscular adaptation and fear of re-injury. The continued reduction in rTR one year after ACLR may be a combination of this neuromuscular adaptation and the biomechanical impact of the reconstruction.

TRIAL REGISTRATION

The trial was registered in the Dutch Trial Register (NTR: www.trialregister.nl , registration ID NL7686).

Protocol for a Randomized Crossover Trial to Evaluate the Effect of Soft Brace and Rigid Orthosis on Performance and Readiness to Return to Sport Six Months Post-ACL-Reconstruction

A randomized crossover trial was designed to investigate the influence of muscle activation and strength on functional stability/control of the knee joint, to determine whether bilateral imbalances still occur six months after successful anterior cruciate ligament reconstruction (ACLR), and to analyze whether the use of orthotic devices changes the activity onset of these muscles. Furthermore, conclusions on the feedforward and feedback mechanisms are highlighted. Therefore, twenty-eight patients will take part in a modified Back in Action (BIA) test battery at an average of six months after a primary unilateral ACLR, which used an autologous ipsilateral semitendinosus tendon graft. This includes double-leg and single-leg stability tests, double-leg and single-leg countermovement jumps, double-leg and single-leg drop jumps, a speedy jump test, and a quick feet test. During the tests, gluteus medius and semitendinosus muscle activity are analyzed using surface electromyography (sEMG). Motion analysis is conducted using Microsoft Azure DK and 3D force plates. The tests are performed while wearing knee rigid orthosis, soft brace, and with no aid, in random order. Additionally, the range of hip and knee motion and hip abductor muscle strength under isometric conditions are measured. Furthermore, patient-rated outcomes will be assessed.

Patients older than 55 years regain sporting and recreational activities after arthroscopic anterior cruciate ligament reconstruction

PURPOSE

(1) To compare sporting and recreational activity levels before and at a minimum 6 year follow-up, and (2) to assess the clinical and functional outcomes after anterior cruciate ligament (ACL) reconstruction in patients older than 55 years.

METHODS

A retrospective evaluation of prospectively collected data of 150 patients with a mean age of 64 ± 4.5 (57-74) years was evaluated 8.6 ± 1.4 (6-11) years after primary ACL reconstruction using hamstring autograft. All patients were assessed using the International Knee Documentation Committee scoring system (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner activity level, and visual analog scale (VAS) for pain. The level of recreational activities was assessed using a sport-specific questionnaire. All patients were categorized according to Isolated and Combined ACL injury groups.

RESULTS

The data of 125 patients were analyzed at the last follow-up. While 25 patients were lost to follow-up, 117 of 125 patients were active before their injury in at least one sports discipline compared to 121 of 125 patients after ACL reconstruction. One hundred and two (82%) patients had returned to their recreational activities at the final follow-up. The mean IKDC subjective score increased from 49.5 ± 23.2 (11.5-100) to 76.2 ± 14.8 (33.3-100) (p < 0.0001). The mean KOOS sport increased significantly from 36 ± 36.2 (0-100) to 74.1 ± 25.5 (0-100) (p < 0.0001). The mean VAS score improved from 6.0 ± 2.6 (0-10) to 1.0 ± 1.4 (0-6) (p < 0.0001). There was no significant difference in the median Tegner activity level (preoperative 5 (2-8) vs. follow-up 5 (2-8) (n.s). There was no significant difference in the number of sports disciplines and duration when comparing pre-injury and mid-term follow-up activity after ACL reconstruction. High-impact activities experienced a significant decline, while a significant increase in participation in low-impact activities was recorded.

CONCLUSION

The majority of patients with symptomatic instability regained their pre-injury recreational activity level with excellent clinical and functional outcomes after arthroscopic ACL reconstruction. Nevertheless, a change from high-to low-impact activities has been observed.

LEVEL OF EVIDENCE

Level IV.

Biomechanical Effects of Prophylactic Knee Bracing on Anterior Cruciate Ligament Injury Risk: A Systematic Review

OBJECTIVE

Prophylactic knee braces (PKBs) are widely used by athletes in pivoting and landing sports and have the potential to influence knee movement and alignment, thus modulating anterior cruciate ligament (ACL) injury risk. This systematic review analyses current evidence on the biomechanical effects that PKBs have in the prevention of ACL injuries.

DATA SOURCES

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Searches were conducted on PubMed, Web of Science, Scopus, Ovid MEDLINE, EMBASE, Cochrane, and CINAHL for studies published from inception until May 31, 2021. Included studies assessed the effects of PKBs on biomechanical variables associated with ACL injuries in landing or pivoting tasks, comparing between braced and unbraced conditions.

MAIN RESULTS

A total of 234 articles were identified; from which, 14 controlled, laboratory, biomechanical studies were included in this review. The effects of PKBs on knee biomechanics could be divided into kinematic variables in the coronal, sagittal, and transverse planes; and common kinetic variables, such as ground reaction force (GRF) and ACL load/strain. Also, PKBs were found to have protective effects in coronal and transverse plane kinematics, but results in the sagittal plane were inconclusive. Assessing knee kinetics, PKBs were advantageous in decreasing ACL load/strain but had no significant effect on GRF.

CONCLUSIONS

Prophylactic knee braces may serve to reduce ACL injury risk by modulating knee coronal and transverse plane movements and ACL load/strain during high-risk maneuvres. Precise recommendations are limited by study heterogeneity. More prospective studies are needed to assess ACL injury risk during high-risk sports using specific PKBs.

Return to rugby following musculoskeletal injuries: A survey of views, practices and barriers among health and sport practitioners

STUDY DESIGN AND SETTING

Returning rugby players to the sport following musculoskeletal injuries is a multi-factorial and challenging process. A cross-sectional observational study was conducted among health and sport practitioners involved with injured rugby players in South Africa.

OBJECTIVES AND OUTCOME MEASURES

The views, current practices and barriers encountered by health and sport practitioners during return to rugby were investigated using a self-developed online survey.

RESULTS

64 practitioners participated in the survey including physiotherapists, orthopaedic surgeons, biokineticists and sports physicians. Return to sport (RTS) protocols were considered important, however, participants also indicated that they were slightly more likely to use anecdotal protocols compared to published protocols. Time frames, stages of healing, pain and subjective ratings along with functional outcome measures (such as range of motion, muscle function and proprioception) and sport-specific skills were rated as important and commonly utilised in different RTS phases (i.e., return to non-contact, return to contact and return to matches). The most commonly perceived barriers encountered were related to lack of access and time-constraints.

CONCLUSION

Return to rugby guidelines with consideration of a broad range of criteria and common barriers encountered should be developed to facilitate safe, practical and time-efficient return to rugby following musculoskeletal injuries.

Changes in subjective knee function and psychological status from preoperation to 6 months post anterior cruciate ligament reconstruction

Purpose

To determine characteristic changes in subjective knee function, kinesiophobia, and psychological readiness to return to sports between scores taken before anterior cruciate ligament reconstruction (ACLR) and those taken 6 months post-ACLR.

Methods

Thirty-two participants (median age, 20.0 years) were included. Subjective knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). The Tampa Scale for Kinesiophobia (TSK-11) and Anterior Cruciate Ligament Return to Sport after Injury (ACL-RSI) scale were used to evaluate kinesiophobia and psychological readiness to return to sport, respectively. Questionnaires were administered 1 day before surgery and at 6 months post-ACLR. A positive change was defined as an increase in IKDC-SKF and ACL-RSI scores and a decrease in TSK-11 score. The change in each score from pre-ACLR to 6 months post-ACLR was analyzed using a paired t-test. The percentage change in scores was calculated, and the correlations of the percentage change in the TSK-11 and ACL-RSI scores and that in the IKDC-SKF score were analyzed.

Results

All scores differed significantly positively from pre-ACLR to 6 months post-ACLR. The proportion of participants whose scores did not change positively from pre-ACLR to 6 months post-ACLR was higher for the TSK-11 (38.0%) and ACL-RSI (38.0%) than for the IKDC-SKF (6.3%). No correlation was observed between the percentage change in the IKDC-SKF score and that in the TSK-11 or ACL-RSI scores from pre-ACLR to 6 months post-ACLR.

Conclusions

Changes in subjective knee function and psychological status from pre-ACLR and 6 months post-ACLR may not be interdependent.