Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction in the Adolescent Athlete

Factor structure and measurement invariance of exercise self-efficacy scale among secondary school students in China

Exercise Self-Efficacy Scale (ESES) is widely used to assess individuals' exercise self-efficacy through self-reporting. It includes one factor and 18 items that gauge one's confidence in exercising under various conditions, such as when tired, stressed, or in unfavourable weather. Evidence indicates that differences in the original factor structure and psychometric properties were observed across different populations, including school-age students, university students, and adults. This study examined the factor structure, reliability, convergent validity, and measurement invariance of the Chinese version of the ESES among secondary school students. Data from 856 students (age: M = 13.80, SD = 0.94) were analysed using exploratory and confirmatory factor analyses to identify the best-fitting factor structure. The reliability and convergent validity were tested using the collected data. Configural, metric, and scalar invariances, as well as the likelihood ratio test, were tested for measurement invariance. A 14-item, two-factor structure of the ESES, consistently demonstrated the best fit among secondary school students. The two-factor structure showed strong internal consistency reliability (McDonald's Omega of 0.921 and 0.843) and satisfactory convergent validity (average variance extracted values of 0.582 and 0.478, composite reliability values of 0.917 and 0.845). Multi-group confirmatory factor analysis (likelihood ratio test, p > 0.01) revealed scalar measurement invariance across sex, ethnic backgrounds, grades, and school locations. These findings suggest that the 14-item, two-factor Chinese version of the ESES is suitable for use with secondary-school students. Future studies could confirm these findings by examining the 14-item, two-factor ESES in diverse samples, considering ethnicity, socioeconomic status, and age range.

Survival Analysis of ACL Graft and Contralateral ACL Ruptures in Patients Younger Than 18 Years

Background

Although high rates of graft and contralateral anterior cruciate ligament (ACL) ruptures have been reported in younger patients after ACL reconstruction (ACLR), recent evidence suggests that previously reported crude event rates underestimate the actual event risk.

Purpose

To report rates of graft and contralateral ACL rupture after ACLR in a large series of younger patients using survival analysis.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients aged <18 years at the time of primary ACLR were identified from a single-surgeon database over 12 years ending January 2018. Patients with a previous contralateral ACL rupture or bilateral ACL ruptures were excluded. Overall, 388 patients (204 males, 184 females) were included in the final dataset. Bespoke survey data and clinic follow-up data were used to record graft rupture and contralateral ACL rupture events. Rates of graft and contralateral ACL rupture were calculated using Kaplan-Meier survival analysis. Log-rank tests were used to compare survival functions between several subgroups.

Results

According to Kaplan-Meier survival analysis, the cumulative rates at 2, 5, and 10 years for graft rupture were 11%, 17%, and 22%, and the cumulative rates for contralateral ACL injury were 7%, 19%, and 33%. Males had significantly greater rates of graft rupture than females throughout a 10-year follow-up period (P < .001). Contralateral ACL rupture survival functions were not significantly different between the sexes, although rates were higher in females until 5 years postoperatively, after which contralateral ACL ruptures increased in males, with a cumulative rate of 39% at 10 years compared with 29% for females. Survival rates did not vary between different age groups (<16 vs ≥16 years), but females with a graft diameter of <7 mm on the femoral side had significantly greater graft rupture rates than females with grafts ≥7 mm (P = .04).

Conclusion

The present study is one of the largest consecutive series of younger patients, with one of the longest follow-up periods, reporting a high risk for a second ACL injury. Over time, the cumulative risk for contralateral ACL rupture was higher than for graft rupture. In males, the risk for contralateral ACL rupture continued to increase after 5 years.

Males have higher psychological readiness to return to sports than females after anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Objectives

To examine sex differences in psychological readiness to return to sport following anterior cruciate ligament (ACL) reconstruction as well as to determine whether males and females separately fulfilled cut-off values (≥65) of psychological readiness necessary to return to sport.

Information sources

Web of Science, Scopus and PubMed were comprehensively searched from inception to January 2024 to identify relevant studies.

Eligibility criteria

Observational investigations that compared males and females with a history of ACL reconstruction concerning psychological readiness to return to sport.

Risk of bias

Studies were rated using the Methodological Index for Non-Randomised Studies.

Included studies

Only 11 reports fulfilled the eligibility criteria and were included in the quantitative analysis. A total of 2618 participants were subjected to the primary ACL reconstruction, out of 1631 males and 987 females. Psychological readiness to return to sport was evaluated approximately 9±2.9 months following surgery.

Synthesis of results

The main findings demonstrated that males had slightly higher psychological readiness to return to the sport than females (standardised mean difference 0.33; 95% CI 0.14 to 0.52; p=0.0007; I2=77%) after ACL surgery. In addition, the mean psychological readiness to return to the sport of males was 70.1±8.8 points and of females 65.1±8.8 points, indicating that both sexes exceeded recommendations necessary to return to sport.

Conclusion

Males had slightly higher psychological readiness to return to sport than females approximately 9±2.9 months after ACL reconstruction and both sexes exceeded the highlighted recommendations necessary to return to sport.

PROSPERO registration number

CRD42024497769: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024497769.

Task-Driven Neurophysiological qEEG Baseline Performance Capabilities in Healthy, Uninjured Division-I College Athletes

Background

Athletic performance can be measured with a variety of clinical and functional assessment techniques. There is a need to better understand the relationship between the brain's electrical activity and the body's physiological performance capabilities in real-time while performing physical tasks related to sport. Orthopedic functional assessments used to monitor the neuroplastic properties of the central nervous system lack objectivity and/or pertinent functionality specific to sport. The ability to assess brain wave activity with physiological metrics during functional exercises associated with sport has proven to be difficult and impractical in real-time sport settings. Quantitative electroencephalography or qEEG brain mapping is a unique, real-time comprehensive assessment of brain electrical activity performed in combination with physiometrics which offers insight to neurophysiological brain-to-body function. Brain neuroplasticity has been associated with differences in musculoskeletal performance among athletes, however comparative real-time normal data to benchmark performance capabilities is limited.

Purpose/Design

This prospective, descriptive case series evaluated performance of task-driven activities using an innovative neurophysiological assessment technique of qEEG monitored neurophysiological responses to establish a comparative benchmark of performance capabilities in healthy, uninjured Division-I athletes.

Methods

Twenty-eight healthy uninjured females (n=11) and males (n=17) NCAA Division-I athletes participated in real-time neurophysiological assessment using a Bluetooth, wireless 21-channel dry EEG headset while performing functional activities.

Results

Uninjured athletes experienced standard and regulated fluctuations of brain wave activity in key performance indicators of attention, workload capacity and sensorimotor rhythm (SMR) asymmetries.

Conclusion

qEEG neurophysiological real-time assessment concurrent with functional activities in uninjured, Division-I athletes may provide a performance capability benchmark. Real-time neurophysiological data can be used to monitor athletes' preparedness to participate in sport, rehabilitation progressions, assist in development of injury prevention programs, and return to play decisions. While this paper focuses on healthy, uninjured participants, results underscore the need to discen pre-injury benchmarks.

Level of Evidence

4.

Return to Soccer After Acute Anterior Cruciate Ligament Primary Repair: A 2-Year Minimum Follow-up Study of 50 Amateur Players

BACKGROUND

Return to sport (RTS) after treatment of an anterior cruciate ligament (ACL) tear is a critical parameter to assess the outcome of a surgical procedure. However, few studies have investigated RTS after ACL repair.

PURPOSE

To evaluate RTS of a group of amateur soccer players at a minimum follow-up of 2 years after ACL repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of all patients treated with acute ACL repair was conducted. A total of 50 amateur soccer players were included in the study. Patients were examined clinically or contacted to complete postoperative patient-reported outcome measures, namely the Knee injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee questionnaire, the ACL-Return to Sport After Injury scale, and the Forgotten Joint Score-12.

RESULTS

The patients' mean age was 25.8 ± 7.7 years (range, 14-47 years), and the mean follow-up was 34.3 ± 10.7 months (range, 24-51.3 months). The median Tegner Activity Scale score was 9. The ACL repair failure rate was 16% (8/50). The mean time from repair to failure was 23.1 ± 12.7 months (range, 6-44 months), and the mean age of patients who sustained ACL repair failure was 19.9 ± 3.3 years (range, 14-24 years), significantly lower compared with patients who did not experience ACL repair failure (26.9 ± 7.9 years; range, 16-47 years; P = .017). Multivariate analysis showed that age ≤21 years was the only significant risk factor for ACL repair failure (odds ratio, 5.45; confidence interval, 1.24-27.91; P = .041). Excluding the 8 patients who experienced repair failure, 31 of 42 patients (73.8%) returned to soccer after ACL repair, with 29 of the 31 (93.5%) returning at their preinjury level of play. Moreover, patients who played competitive soccer and returned to their preinjury level of play were significantly younger than those who did not return to their preinjury level of play (mean, 21.1 ± 3.4 vs 29.2 ± 9.5 years, respectively; P = .002) and had significantly better ACL-Return to Sport After Injury scores (mean, 96.6 ± 4 vs 87.8 ± 11, respectively; P = .044).

CONCLUSION

In this study, 73.8% (n = 31) of patients returned to playing soccer, of whom 93.5% (n = 29) returned to their preinjury level after ACL repair. The failure rate was 16% (n = 8) and mainly involved patients ≤21 years old.

Measurement properties of the Swedish version of the anterior cruciate ligament return to sport after injury scale (ACL-RSI): A Rasch analysis

Purpose

This study aimed to investigate the measurement properties, according to the Rasch Measurement Theory, of the anterior cruciate ligament return to sport after injury scale (ACL-RSI) in patients treated with ACL reconstruction in Sweden.

Methods

ACL-RSI responses from 1065 patients treated with ACL reconstruction were extracted from a rehabilitation-specific registry. Rasch analyses were performed on ACL-RSI item response data using the RUMM2030plus software. The analyses focused on targeting (person-item threshold distribution), item hierarchy, response category thresholds, overall and individual item and person fit, differential item functioning (DIF), unidimensionality and reliability.

Results

The ACL-RSI had compromised fit to the Rasch model, including DIF and malfunctioning response categories. Several items correlate with each other and the presumptions to aggregate item responses into one single score were not met. When accounting for local dependency, the measurement properties of the ACL-RSI improved in terms of model fit and DIF and unidimensionality were supported.

Conclusion

The ACL-RSI was found to have signs of multidimensionality and local dependency, that is, the answers to one item are influenced by the answers to other items. As such, researchers should be careful when using the ACL-RSI as one single score to evaluate patients treated with ACL reconstruction, unless local dependency is accounted for in the scoring process.

Level of Evidence

Level III.

Management of Anterior Cruciate Ligament Tears in Skeletally Immature Patients

PURPOSE OF REVIEW

Anterior cruciate ligament (ALC) tears are increasingly common in skeletally immature patients, as more children and adolescents participate in intensive sports training and specialization at increasingly younger ages. These injuries were historically treated nonoperatively, given concerns for physeal damage and subsequent growth disturbances after traditional ACL reconstruction techniques. However, there is now sufficient data to suggest superior outcomes with operative treatment, specifically with physeal-sparing and physeal-respecting techniques. This article reviews considerations of skeletal maturity in patients with ACL tears, then discusses surgical techniques, with a focus on their unique indications and outcomes. Additional surgical adjuncts and components of postoperative rehabilitation, which may reduce retear rates, are also considered.

RECENT FINDINGS

Current research shows favorable patient-reported outcomes and high return-to-sport rates after ACL reconstruction in skeletally immature patients. Graft rupture (ACL retear) rates are low, but notably higher than in most adult populations. Historically, there has been insufficient research to comprehensively compare reconstruction techniques used in this patient population. However, thoughtful systematic reviews and multicenter prospective studies are emerging to address this deficit. Also, more recent data suggests the addition of lateral extra-articular procedures and stringent return-to-sports testing may lower retear rates. Physeal-sparing and physeal-respecting ACL reconstructions result in stabilization of the knee, while respecting the growth remaining in children or skeletally immature adolescents. Future research will be essential to compare these techniques, given that more than one may be appropriate for patients of a specific age and skeletal maturity.

Outcomes After Anterior Cruciate Ligament Reconstruction With Quadriceps Tendon in Adolescent Athletes at Mean Follow-up of 4 Years

Background

Despite increasing use of quadriceps tendon (QT) autograft in anterior cruciate ligament (ACL) reconstruction (ACLR), limited data exist regarding its outcomes in high-risk adolescent athletes.

Purpose

To (1) report the outcomes after QT ACLR in adolescent athletes and (2) identify patient-related and surgery-related factors that may influence failure rates after QT ACLR.

Study Design

Case series; Level of evidence, 4.

Methods

All patients aged 14 to 17 years who underwent primary anatomic, transphyseal, single-bundle QT ACLR between 2010 and 2021 with a minimum 2-year follow-up were included for analysis. Demographic and surgical data as well as preoperative International Knee Documentation Committee (IKDC) and Marx activity scores were collected retrospectively. All patients were also contacted to assess postoperative patient-reported outcomes (PROs), including IKDC and Marx activity scores, and return-to-sports (RTS) data. Outcomes of interest included rates of revision ACLR and ipsilateral complications, contralateral ACL tears, difference in pre- and postoperative PROs, and rates of RTS. Patient and surgical characteristics were compared between groups who required revision ACLR versus those who did not.

Results

A total of 162 patients met inclusion criteria, of which 89 adolescent athletes (mean age 16.2 ± 1.1 years, 64% female) were included for analysis at mean follow-up of 4.0 years. Postoperative IKDC scores were significantly higher than preoperative scores (88.5 vs 37.5; P < .001), whereas Marx activity scores decreased postoperatively (14.3 vs 12.2; P = .011). Successful RTS occurred in 80% of patients at a mean time of 9.7 ± 6.9 months, and 85% of these patients returned to the same or higher level of sports. The most common reasons for failure to RTS included lack of time (n = 7, 70%) and fearing reinjury in the operative knee (n = 5, 50%). The overall revision ACLR rate was 10% (n = 9), and contralateral ACL tears occurred in 14% (n = 12) of patients. The overall ipsilateral knee reoperation rate was 22.5% (n = 20). No statistically significant differences in patient or surgical characteristics were observed between patients who underwent revision ACLR and those who did not.

Conclusion

At a minimum 2-year follow-up after QT ACLR, adolescent athletes experienced significantly improved postoperative IKDC scores, high rates of RTS, and low rates of graft failure, despite a relatively high ipsilateral reoperation rate. Surgeons may utilize this information when identifying the optimal graft choice for adolescent athletes who have sustained an ACL injury and wish to return to high level of sporting activities.

Anterior cruciate ligament-Return to sport after injury scale brief version after ACL reconstruction: Persian translation, cross-cultural adaptation and validation

PURPOSE

The purpose of this study is to analyze the short anterior cruciate ligament return to sport after injury (ACL-RSI) (Persian) version's cultural adaption and validity.

METHODS

To assess test-retest reliability, 102 participants were filled out the short ACL-RSI(Per) scale 6 months or more after ACLR surgery. Internal consistency (Cronbach's alpha), test-retest reliability (intraclass correlation coefficients), construct validity (Pearson's r) and sensitivity (floor/ceiling effect) were determined. In addition, patient completed other relevant measures such as Lysholm scores, the hospital for special surgery ACL satisfaction survey (HSS ACL-SS), the visual analogue scale (VAS) of pain and patient's satisfaction, the Tegner activity score (TAS), the single assessment numeric evaluation (SANE) and the Cincinnati Knee Rating System (CKRS).

RESULTS

The short ACL-RSI(Per) scale showed high internal consistency (Cronbach's alpha = 0.91) and test-retest reliability (ICC = 0.923). Significant correlations between short ACL-RSI(Per) and other scales supported validity. There was a statistically significant connection between the short ACL-RSI(Per) and the following outcomes: HSS ACL-SS (r = 0.698, p < 0.001), VAS pain (r = 0.356, p < 0.001), CKRS (r = 0.644, p < 0.001), TAS (r = 0414, p < 0.001), Lysholm score (r = 0.467, p < 0.001) and SANE score (r = 0.536; p < 0.001). In addition to a satisfactory ceiling impact (15%), a sizeable floor effect (16.7%) was also seen.

CONCLUSION

The short ACL-RSI(Per) scale is a reliable and valid tool for assessing psychological readiness for return to sport after ACL reconstruction in Persian.

LEVEL OF EVIDENCE

III.

The Influence of Psychosocial Factors on Patients Undergoing Anterior Cruciate Ligament Reconstruction

CONTEXT

Anterior cruciate ligament (ACL) injuries greatly impact patients in terms of future performance, reduced physical activity and athletic participation, and overall economic burden. Decades of research have investigated how to improve ACL reconstruction (ACLR) outcomes. Recently, there has been growing interest to understand the effects of psychosocial factors on patient outcomes.

STUDY DESIGN

Clinical review.

EVIDENCE ACQUISITION

A search of the PubMed database was performed in March 2023. Articles were reviewed by at least 2 authors to determine relevance. We highlighted publications of the past 5 years while incorporating previous pertinent studies.

LEVEL OF EVIDENCE

Level 5.

RESULTS

There is no standardization of psychosocial factors regarding ACLR. As such, there is a lack of consensus regarding which psychosocial measures to use and when. There is a need for clarification of the complex relationship between psychosocial factors and physical function. Despite this, psychosocial factors have the potential to help predict patients who are more likely to return to sport: (1) desire/motivation to return; (2) lower levels of kinesiophobia; (3) higher levels of self-efficacy, confidence, and subjective knee function; (4) risk acceptance; and (5) social support. However, there are no standardized interventions to improve psychosocial factors after ACLR.

CONCLUSION

Psychosocial factors affect outcomes after ACLR. However, the interplay between psychosocial factors and physical function is complex. There is emerging evidence that testing and interventions may improve ACLR outcomes. There is a lack of standardized interventions to determine or improve psychosocial factors after ACLR. Further research is needed to identify psychosocial factors and to develop standardized interventions for clinicians to implement to improve clinical outcomes.

Current Rehabilitation Practices and Return to Sports Criteria After Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists in Saudi Arabia

CONTEXT

With the high prevalence of anterior cruciate ligament rupture among young and active individuals, rehabilitation after the injury and surgery should meet the current evidence-based recommendations to restore knee function and reduce the risk of further injury. This study aimed to investigate the current rehabilitation practices and return to sports (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) among physical therapists in Saudi Arabia.

DESIGN

Online cross-sectional survey-based study.

METHODS

A total of 177 physical therapists in Saudi Arabia participated in this survey. The survey included questions about the preferred postoperative timing and frequency of rehabilitation, current views on the importance of preoperative and postoperative rehabilitation to the overall outcomes, the timeframe of RTS, and the decision-making process to RTS.

RESULTS

Most therapists (96.6%) believed preoperative rehabilitation was essential/important to postoperative outcomes. Two-thirds encouraged patients to start rehabilitation program within 1 to 4 days immediately post-ACLR. RTS was permitted 6 to 9 months post-ACLR by 60% of therapists if satisfied with patient progress and capacity. Factors considered before RTS included knee strength (72.9%), functional capacity (86.4%), lower limb and trunk mechanics (62.7%), and psychological readiness (42.2%). Knee strength was assessed by manual muscle testing (39%), handheld dynamometry (15.3%), and isokinetic dynamometer (13.6%). While 60% of the therapists used single-limbed hop for distance for evaluating functional capacity, only 27.1% used a hop test battery.

CONCLUSIONS

The surveyed physical therapists in Saudi Arabia demonstrated variations in the current rehabilitation practices and RTS criteria post-ACLR. Over half of the surveyed therapists considered preoperative rehabilitation essential to postoperative outcomes. However, the therapists should update their perspective with current evidence-based practice regarding the RTS timeframe, psychological readiness assessment for RTS, and knee strength evaluation using objective measurements.

The Risk Factors and Preventive Strategies of Poor Knee Functions and Osteoarthritis after Anterior Cruciate Ligament Reconstruction: A Narrative Review

Anterior cruciate ligament reconstruction (ACLR) is the standard surgical treatment for ACL injury, which typically uses a graft to replace the torn ligament in the knee that uses small incisions with minimally invasive surgery. The optimal knee functions following ACLR depend on rehabilitation processes before and after the surgery. Knee function is the ability of the knee to perform various types of functional movements like walking, squatting, running, jumping, and pivoting where patients expect to achieve maximum knee function or at least more than 80% of its initial condition before the injury to avoid being categorized as poor knee function after ACLR. Patients use patient-reported outcome measures to collect data on their health status and quality of life after ACLR. Post-traumatic osteoarthritis (PTOA) is a type of OA that manifests in local cartilage injury caused by chondrocyte death, and matrix dispersion occurs following a joint injury like ACL injury. Gender, time from injury to surgery, and graft type were considered as risk factors for poor knee function after ACLR, while overweight, meniscus tear, and cartilage defect as risk factors for PTOA. However, age is an internal risk factor for both poor knee function and PTOA following ACLR. This review suggests several strategies to prevent both conditions, including a pre-operative program, comprehensive rehabilitation, body weight control, and return to sport (RTS) consideration based on physical capacity, proper time, and psychological readiness.

Validation of the ACL-RSI Scale in Pediatric and Adolescent Patients

BACKGROUND

The Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale is a 12-item questionnaire assessing psychological readiness to return to sport after anterior cruciate ligament reconstruction. It has been validated for use in adults in multiple languages and in an abbreviated 6-question short form. Additionally, literature has been published using this scale in pediatric and adolescent populations, however it has not yet been validated for use with them.

PURPOSE

To validate the ACL-RSI scale for use with pediatric and adolescent patients.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 2.

METHODS

Scores of 6- and 12-item ACL-RSI scales for patients undergoing return-to-sport readiness testing 6 to 8 months after anterior cruciate ligament reconstruction were analyzed. Convergent validity testing was performed against the International Knee Documentation Committee (IKDC)/Pediatric IKDC score, Single Assessment Numeric Evaluation (SANE) score, and peak torque asymmetry of knee flexion and extension using Spearman correlations. Discriminant validity testing was performed against age (Spearman correlation), body mass index (Spearman correlation), and sex (Mann-Whitney U test). Reliability testing was performed by calculating Cronbach's alpha. Floor and ceiling effects were assessed by calculating the number of minimum and maximum scores in the cohort.

RESULTS

A total of 51 patients were included in the final analysis. The mean age at surgery was 15.2 ± 2.2 years, and 51.0% were female. The 6- and 12-item ACL-RSI scales demonstrated a strong significant positive correlation with IKDC/Pediatric IKDC scores (R = 0.723 and 0.717, respectively; P < .001) and moderate significant positive correlation with Single Assessment Numeric Evaluation scores (R = 0.516 and 0.502, respectively; P < .001) Age at surgery, body mass index, and sex were not correlated with either ACL-RSI scale. Cronbach's alpha values of the 12- and 6-item ACL-RSI scales in this population were 0.959 and 0.897, respectively. For both the 12- and the 6-item ACL-RSI scales, no floor or ceiling effects were found as the minimum score (0) was not observed in either version, and the maximum score (100) was only observed twice (3.9%) in both versions.

CONCLUSION

The ACL-RSI scale is valid to use with pediatric and adolescent patients. The 6-item scale may be a better choice because it has fewer redundancies and minimizes the risk of questionnaire fatigue.