Altered postural sway persists after anterior cruciate ligament reconstruction and return to sport

Postural sway is defined as the movement of a body's center of mass within the base of support to maintain postural equilibrium. Deficits in postural sway are present after ACL injury; however, current evidence linking it to future injury risk is unclear. The purpose of this study was to determine if postural sway deficits persist after ACL reconstruction (ACLR). The hypothesis tested was that after ACLR, patients who return to sport (RTS) would demonstrate differences in postural sway compared to control (CTRL) subjects. Fifty-six subjects with unilateral ACLR released to RTS, and 42 uninjured CTRL subjects participated. Dynamic postural sway was assessed and 3-way (2 × 2 × 2) ANOVA was used to analyze the variables. A side × group × sex (p = 0.044) interaction in postural sway was observed. A side × group analysis also revealed an interaction (p = 0.04) however, no effect of sex was observed (p = 0.23). Analysis within the ACLR cohort showed less (p = 0.001) postural sway on the involved side (1.82 ± 0.84°) versus the uninvolved side (2.07 ± 0.96°). No side-to-side differences (p = 0.73) were observed in the CTRL group. The involved limb of subjects after ACLR demonstrated the least postural sway. In conclusion, these findings indicate that dynamic postural sway may be significantly altered in a population of athletes after ACLR and RTS compared to CTRL subjects. Further investigation is needed to determine if deficits in postural sway can be used as an effective criterion to assist in the decision to safely RTS after ACLR.     

Cognitive-behavioral-based physical therapy to enhance return to sport after anterior cruciate ligament reconstruction: An open pilot study

ObjectivesTo describe feasibility, adherence, acceptability, and outcomes of a cognitive-behavioral-based physical therapy (CBPT-ACLR) intervention for improving postoperative recovery after anterior cruciate ligament reconstruction (ACLR).DesignPilot study.SettingAcademic medical center.ParticipantsEight patients (mean age [SD] = 20.1 [2.6] years, 6 females) participated in a 7-session telephone-based CBPT-ACLR intervention beginning preoperatively and lasting 8 weeks after surgery.Main outcome measuresAt 6 months, patients completed Knee Injury and Osteoarthritis Outcome Score (KOOS) sports/recreation and quality of life (QOL) subscales, International Knee Documentation Committee (IKDC), Tampa Scale of Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), and Knee Self-Efficacy Scale (K-SES), return to sport (Subjective Patient Outcome for Return to Sports), and satisfaction. Minimal clinically important difference (MCID) was used for meaningful change.ResultsSeven (88%) patients completed all sessions. Seven (88%) patients exceeded MCID on the TSK, 6 (75%) on the PCS, 5 (63%) on the KOOS sports/recreation subscale, 4 (50%) on the IKDC, and 3 (38%) on the KOOS QOL subscale. Three (38%) patients returned to their same sport at the same level of effort and performance. All patients were satisfied with their recovery.ConclusionsA CBPT-ACLR program is feasible and acceptable for addressing psychological risk factors after ACLR.     

Patient expectations and perceived social support related to return to sport after anterior cruciate ligament reconstruction in adolescent athletes

ObjectiveExamine the relationship between pre-operative competitive status and return to sport expectations post-operatively among adolescents undergoing ACL reconstruction. Assess the association between perceived levels of social support and doubts in returning to sport after ACL reconstruction.DesignCross-sectional.SettingOutpatient sports medicine clinic at a single institution.Participants12–18 years old with an ACL tear who were planning to undergo ACL reconstruction.Main outcome measuresPsychovitality questionnaire responses and Multidimensional Scale of Perceived Social Support (MSPSS) questionnaire scores.Results86% of participants expected to return to sports in six months or less after surgery; there was no significant difference in expected time to return to sport between competitive vs. recreational athletes. Competitive athletes were less likely to be content returning to a lower activity level after surgery compared to recreational athletes. There were no significant differences in MSPSS scores between those who did and did not report doubts in their ability to return to their previous sports.ConclusionMost of our adolescent athlete population expected to return to sport after ACL reconstruction within six months of surgery. Those with and without doubts in their ability to return to sports did not significantly differ in levels of perceived social support.     

Young athletes return too early to knee-strenuous sport,without acceptable knee function after anterior cruciate ligament reconstruction

Purpose

The purpose of this study was to evaluate the return to knee-strenuous sport rate, muscle function and subjective knee function among adolescent patients (15–20 years of age) and adult patients (21–30 years of age) 8 and 12 months, respectively, after anterior cruciate ligament (ACL) reconstruction. It was hypothesised that no differences in outcome would be found between age groups at 8 or 12 months after ACL reconstruction.

Methods

Cross-sectional data from five tests of muscle function, from the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Tegner Activity Scale (Tegner), performed at 8 and 12 months after a primary ACL reconstruction, were extracted from a rehabilitation outcome register. A total of 270 (51% women) athletes, aged 15–30 years, who were all involved in knee-strenuous sport prior the injury, were included at 8 months after ACL reconstruction. At 12 months 203 (51% women) were included. The return to knee-strenuous-sport rates and the rate of achieving a limb symmetry index of ≥ 90% in all five tests of muscle function, defined as recovery of muscle function, and subjective knee function scores, as measured with the KOOS, were compared between age groups.

Results

The adolescent patients had a higher (50%) return to knee-strenuous sport rate compared with the adult patients (38%) 8 months after ACL reconstruction (p?=?0.04). At the 12-month follow-up, no difference was found between the age groups; 74 and 63%, respectively. At the 8-month follow-up, 29% of the patients, in both age groups, who had returned to sport had recovered their muscle function in all five tests of muscle function. At the 12-month follow-up, the corresponding results were 20% for the adolescents and 28% for the adult patients. No difference in mean KOOS scores was found between the age groups at 8 or at 12 months after ACL reconstruction.

Conclusion

The majority of young athletes make an early return to knee-strenuous sport after a primary ACL reconstruction, without recovering their muscle function. To set realistic expectations, clinicians are recommended to ensure that young athletes receive information about not to return before muscle function is recovered and that this may take longer time than 12 months.

Level of evidence

II.

     

Preoperative quadriceps strength as a predictor of return to sports after anterior cruciate ligament reconstruction in competitive athletes

ObjectivesTo determine whether preoperative quadriceps strength predicts the likelihood of return to sports (RTS) following anterior cruciate ligament reconstruction (ACLR) in competitive athletes.DesignCase-control study.SettingSingle-center.ParticipantsA total of 221 competitive athletes who underwent primary ACLR were followed and divided into RTS (n = 177) and non-RTS (n = 44) groups based on self-reported sports activities at one year postoperatively.Main outcome measuresIsokinetic quadriceps strength tests were performed preoperatively and at six months and one year postoperatively, and the quadriceps index (QI) was calculated. Functional performance was evaluated by the single-leg hop (SLH) test at six months postoperatively.ResultsPreoperative QI significantly predicted the likelihood of RTS (odds ratio, 1.68 per 10-unit increase; P < 0.001), with a preoperative QI cut-off of 66% (AUC: 0.74; sensitivity: 68.9%; specificity: 77.3%). Subjects with a preoperative QI < 66% had a significantly lower postoperative QI, SLH, and rates of RTS compared to those with a higher preoperative QI (P < 0.01).ConclusionsPreoperative quadriceps strength could predict the likelihood of RTS following ACLR, and a preoperative QI < 66% was associated with a greater risk of unsuccessful RTS at one year postoperatively. Preoperative QI should be evaluated as a predictor of RTS.     

Postural control after anterior cruciate ligament reconstruction and functional rehabilitation

Total sagittal knee laxity and postural control in the sagittal and frontal planes were measured in 25 patients at a mean of 36 months (range, 27 to 44) after anterior cruciate ligament reconstruction and in a control group consisting of 20 uninjured age- and activity-matched subjects. Body sway was measured in the sagittal plane on a stable and on a sway-referenced force plate in single-legged stance, double-legged stance, or both, with the eyes open and closed. Postural reactions to perturbations in the sagittal and frontal planes were recorded in the single-legged stance with the eyes open. Total sagittal plane laxity was significantly greater in the anterior cruciate ligament-reconstructed knee (11.2 mm; range, 6 to 15) than in the uninjured knee (8.9 mm; range, 6 to 12) or in the control group (6.0 mm; range, 5 to 8). In spite of this, the patients, in comparison with the controls, exhibited normal postural control except in two variables-the reaction time and the latency between the start of force movement to maximal sway in the sagittal plane perturbations. This supports the hypothesis that rehabilitation, with proprioceptive and agility training, is an important component in restoring the functional stability in the anterior cruciate ligament-reconstructed knee.     

Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy

Purpose

To describe individuals’ expectations, motivation, and satisfaction before, during, and after rehabilitation for ACL reconstruction and to explore how these factors were associated with return to pre-injury sport activity at 1-year follow-up.

Methods

Sixty-five individuals (34 males), median age 22 (15–45) years, scheduled for ACL reconstruction participated. Participants completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) and questions about expectations, satisfaction, and motivation pre-operatively and at 16 and 52 weeks after surgery.

Results

Prior to surgery, 86 % of participants stated that their goal was to return to their pre-injury sport activity. Those who had returned to their pre-injury sport activity at 52 weeks were more motivated during rehabilitation to return to their pre-injury activity level, more satisfied with their activity level and knee function at 52 weeks, and scored significantly higher on the IKDC-SKF [median 92.0 (range 66.7–100.0)] at 52 weeks, compared to those who had not returned [median 77.6 (range 50.6–97.7)].

Conclusion

Prior to ACL reconstruction, most participants expected to return to their pre-injury activity level. Higher motivation during rehabilitation was associated with returning to the pre-injury sport activity. The participants who had returned to their pre-injury sport activity were more satisfied with their activity level and knee function 1 year after the ACL reconstruction. Facilitating motivation might be important to support individuals in achieving their participation goals after ACL reconstruction.

Level of evidence

Prospective cohort study, Level II.

     

Return to play after anterior cruciate ligament reconstruction

The goal of knee ligament reconstruction is to return the athlete to the previous level of function as quickly and as safely as possible. The appropriate level of aggressiveness in returning the athlete to sport remains controversial. Information in the literature regarding safe return to play has been dominated by the anterior cruciate ligament (ACL) reconstruction literature. The basic concepts that hold true for returning the ACL-reconstructed athlete to play can be generalized to injuries treated nonoperatively as well. This article presents a review of the principles of rehabilitation following knee ligament reconstruction, with an emphasis on criteria for return to play.     

Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study

Purpose

The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months.

Methods

Sixty-two ACLR patients performed a test battery at an average of 6.5?±?0.7 and 9.5?±?0.9 months after ACLR. All patients underwent a standardized rehabilitation protocol. The test battery consisted of the following tests: a jump-landing task assessed with the Landing Error Scoring System (LESS), three single-leg hop tasks (single-leg hop test, triple-leg hop test, side hop test), isokinetic quadriceps and hamstring strength at 60, 180 and 300°/s and two questionnaires (IKDC and ACL–RSI). Cut off criteria were set as Limb Symmetry Index (LSI)?>?90% (for isokinetic strength and for single-leg hop tasks), LESS?<?5, IKDC score within 15th percentage of healthy subjects and ACL–RSI?>?56 respectively.

Results

At 6 months, two patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACLR.

Conclusions

The percentages of patients passing all RTS criteria were low at both 6 and 9 months after ACLR. Quadriceps strength revealed persistent deficits and the lack of improvement in the IKDC score questionnaires shows insufficient self-reported knee function for RTS.

Level of evidence

III.

     

Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction

Purpose

The aims of this study were to evaluate the functional recovery before and after ACL reconstruction and to evaluate the sensitivity to change in performance-based and self-reported outcomes prior to and after ACL reconstruction and to determine whether these changes represent clinically relevant improvement.

Methods

Eighty-three athletes participated in this study. Athletes were tested after an ACL injury, after preoperative training, and 6 and 12 months after ACL reconstruction. Athletes completed quadriceps strength testing, hop testing, and self-reported questionnaires for knee function (International Knee Documentation Committee subjective knee form, Knee Outcome Survey-Activities of Daily Living Scale, and the Global Rating Scale of Perceived Function) at each testing period.

Results

A significant interaction of limb by time was seen in normalized quadriceps strength, and single, triple, and 6-m timed hop, where the involved limb improved more than the uninvolved limb over time. A main effect of time was noted for performance-based limb symmetry indexes and self-reported measures.

Conclusion

Limb-to-limb asymmetries are reduced, and normal limb symmetry is restored after perturbation training and aggressive quadriceps strengthening and returned to similar levels 6 months after reconstruction. Performance-based values on the involved limb and self-reported outcomes are sensitive to change over time, and these were clinically relevant improvements.

Level of evidence

Prognostic study, Level II.     

Serial assessments to determine normalization of gait following anterior cruciate ligament reconstruction

There is an increased emphasis to identify clinically applicable methods that quantify gait deficits following anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to perform serial gait assessments in a clinical setting to determine whether and when clinical gait parameters normalize in patients following ACLR. The hypothesis was that a clinically available gait treadmill would quantify gait deficits measured at 4 weeks post-reconstruction. The secondary hypothesis was that patients would demonstrate incremental improvements in these gait parameters measured at each interval up to 12 weeks post-reconstruction, and that the objectively measured improvements would correlate to the patient's subjective rating of function. Fifteen subjects, five male and 10 female, who had initial unilateral anterior cruciate ligament injury were selected for this study on the basis of operative data. All subjects were evaluated in a physical therapy clinic within 3 days following ACLR and were enrolled in a standardized rehabilitation program. The dependent gait variables of step length, stance time and gait velocity were measured at 4, 6, 8 and 12 weeks post-ACLR on a commercially available gait treadmill. A 2 x 4 multivariate analysis of variance (2 within factors) with measures for limb involvement (uninvolved and involved) and repeated measures for time (4, 6, 8 and 12 weeks) was used to assess the interactions and the main effects on the gait variables of stance time and step length. The results of this study supported the hypothesis that gait deficits and serial improvements can be objectively quantified in a clinical setting (P<0.001). Specifically, stance time, step length and gait velocity deficits evaluated at 4 weeks showed significant improvements at the measured intervals. Step length normalized at week 8. Stance time and gait velocity reached normal levels at the 12-week time interval. Subjective activity of daily living scores (ADLS) also improved following the 12-week rehabilitation, from 53+/-17% to a mean score of 88+/-11% (P<0.001). ADLS scores significantly correlated to step length (R=0.63) and stance time (R=0.53) in the involved limb. Self-selected gait velocity also correlated to ADLS scores and significantly predicted 49% of the variance in the subjective outcome measure. A clinically available gait treadmill can be used to quantify gait deficits and improvements following ACLR. Serial assessments of walking gait may aid clinicians to identify and target deficits in their patients during rehabilitation.     

Graft size after anterior cruciate ligament reconstruction

Purpose

The native anterior cruciate ligament (ACL) is composed of two distinct bundles, the anteromedial (AM) and posterolateral (PL), and both have been shown to be reliably measured on magnetic resonance imaging (MRI). The purpose of this study was to measure the size of the AM and PL bundles after ACL double-bundle reconstructions on MRI and compare this to the relative graft size at the time of surgery.

Methods

Between January 2007 and April 2010, 85 knees were identified after allograft double-bundle ACL reconstruction with post-operative MRI (1.5 T) and met inclusion criteria. On standard sagittal, coronal and oblique coronal MRIs, the AM and PL bundles were delineated and the midsubstance width of the ACL graft was measured. The images were independently measured in a blinded fashion by two observers. Linear and curvilinear regression analysis was used to analyse the relationship between graft size and time after reconstruction.

Results

The mean age of the patients was 24.6 years (SD 10.4). Mean time from surgery to post-operative MRI was 271.5 days (SD 183.4). The mean percentage of the original size of the AM bundle was 86.9 % (SD 9.9) and of the PL bundle was 88.6 % (SD 9.9). There was no correlation between the relative size of the AM graft and the time from surgery (r = 0.3, n.s.) and no significant relationship for the PL graft (r = 0.1, n.s).

Conclusion

On average, there was no graft enlargement of the AM and PL grafts 275.1 days after allograft ACL double-bundle reconstruction, as the mean relative graft size was less than 100 % on MRI. This study suggests that surgeons, who use allografts, should measure the ACL and replace it with a similar size, as there is a low risk of hypertrophy of the graft within one year post-operative.

Level of evidence

IV.     

Patellofemoral problems after anterior cruciate ligament reconstruction

Between 1982 and 1986, 126 patients who had undergone ACL reconstruction were followed in a prospective manner. One year follow-up statistics were reviewed for the presence of 13 different complications. The most prevalent complications were quadriceps weakness, flexion contracture, and patellofemoral pain. Quadriceps weakness (strength less than 80% of the normal side) was present in 65% of patients and correlated positively with flexion contracture, patellar irritabibilty, and ACL reconstructions using patellar tendon grafts. Flexion contracture of 5 degrees or more was present in 24% of patients and correlated positively with increased age and patellar irritability. Patellofemoral pain was present in 19% of patients and correlated positively with flexion contracture. Clinical relevance: The three most common complications of knee ligament surgery are shown to be strongly interrelated. It is likely that a causal relationship is present in which flexion contracture causes patellofemoral irritability, and that both of these factors, alone or in combination, result in quadriceps weakness. If this theory is correct, then it is crucial that postoperative rehabilitation programs place a major emphasis on the avoidance of flexion contracture.