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CurrentConceptsReview
Operative Treatment of Primary AnteriorCruciate Ligament Rupture in Adults
Christopher D. Murawski, BS, Carola F. van Eck, MD, PhD, James J. Irrgang, PT, PhD, ATC, FAPTA,Scott Tashman, PhD, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Operative management of an acute anterior cruciate ligament (ACL) rupture may be required in young and active
patients to stabilize the knee and return patients to desired daily activities.
ACL reconstruction should be performed anatomically.
The majority of studies show no differences between anatomic single-bundle and double-bundle ACL recon-
struction with respect to patient-reported outcome scores. Double-bundle reconstruction may provide superior
knee joint laxity measurements compared with the single-bundle technique.
Following ACL reconstruction, the age and activity level of a patient are predictive of his or her time of return to
sports and reinjury.
Concomitant meniscal and/or cartilage damage at the time of surgery, in addition to a persistent knee motion
deficit, are associated with the development of osteoarthritis after ACL reconstruction.
Anterior cruciate ligament (ACL) rupture is a common injuryworldwide. Estimates suggest an annual incidence for ACL ruptureof thirty-five per 100,000 people of all ages1, with an approxi-mately two to eight-times higher risk in female athletes than inmale athletes2-7. These injuries often result in instability of theknee, increased joint laxity, and reduced activity and partici-pation, as well as an increased risk of knee osteoarthritis in thelong term8,9. Surgical reconstruction of the ACL is often rec-ommended, particularly in young and active patients, to facili-
tate a return to the desired daily activities, including sports.As the estimated annual health-care cost of ACL surgeryis $3 billion in the United States alone, providing patients with thebest potential for a successful outcome after ACL reconstruction
remains a topic of intense interest among clinicians and re-searchers10. In this review, a critical assessment of the evidencefor operative treatment of primary ACL rupture in adults (eighteen
years of age or older) is provided, including principles for decisionmaking, clinical outcomes, and guidelines for return to sports.
Anatomy and Function
The ACL is composed of two functional bundles, the antero-medial and posterolateral bundles, which are named for the lo-
cation of their respective insertion sites on the tibia
11,12
. The tibialinsertion site of the ACL reveals a characteristic fan-shaped foot-print, whereas the femoral insertion site demonstrates a smaller,oval-shaped appearance13. The femoral insertion site is identifiable
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more ofthe authors,or his or her institution, has had a financial relationship, in the thirty-six months priorto submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is
written in thiswork.The complete Disclosures of Potential Conflicts of Interest submitted by authorsare always provided with the online version of the article.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editorreviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one ormore exchanges between the author(s) and copyeditors.
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COPYRIGHT 2014 B Y T HE J OURNAL OFB ONE ANDJ OINT S URGERY, INCORPORATED
J Bone Joint Surg Am.2014;96:685-94 d http://dx.doi.org/10.2106/JBJS.M.00196
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using the position of two osseous ridges on the medial wall ofthe lateral femoral condyle14-18. The lateral intercondylar ridge,or so-called residents ridge, denotes the anterior border of thefemoral insertion site. The lateral bifurcate ridge runs perpen-dicular to the lateral intercondylar ridge, between the femoralinsertion sites of the anteromedial and posterolateral bundles19.
Functionally, the anteromedial and the posterolateral bundlesbehave synergistically with knee flexion, whereby both antero-posterior and rotational stability of the knee are provided. In-dividually, the anteromedial bundle length remains constantthroughout the knee flexion-extension, attaining peak tensionbetween 45and 60of flexion20-22. In comparison, the postero-lateral bundle is tight in extension and loosens with flexion,thereby allowing axial rotation of the knee to occur. Varyingmechanical behaviors of the functional bundles of the ACL havebeen reported23,24.
A thorough understanding of the anatomy and functionof the native ACL is fundamental for the treatment of ACL in-
juries. This understanding ultimately aids the surgeon in de-termining the most appropriate treatment strategy for a partialor complete rupture of the ACL.
Treatment of ACL Injuries
ACL injuries can be managed with nonoperative or operativetreatment. The decision to recommend operative treatment foran acute ACL rupture is multifactorial and must be individualizedto each patient on the basis of his or her age25, desired activitylevel, and presence of potential concomitant injuries. In general,
younger and more active patients are more likely to require sur-gery to return to functionally demanding activities. In the re-mainder of this review article, we focus on operative treatment
of ACL injuries. While rehabilitation after ACL reconstructionis an important aspect of the ultimate success after ACL recon-struction25-28, it is not a focus of this review.
Operative Treatment
Once the decision to proceed withoperative treatmentof an ACLrupture is made, timing of the procedure becomes an importantvariable to consider. Preoperative range of motion, swelling,and quadriceps strength have been investigated as factors thatcan affect the ultimate success of ACL reconstruction29,30. Preop-erative swelling and limited range of motion have been related tothe development of arthrofibrosis after surgery29.
Preoperative quadriceps strength deficits of >20% have
been shown to significantly affect the two-year functional out-come of ACL reconstruction with bone-patellar tendon-boneautograft30. Moreover, it has been reported that preoperativequadriceps strength of >90% of that of the noninjured leg sig-nificantly increased postoperative strength two years after sur-gery compared with those with
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bone-patellar tendon-bone graft is not suitable for double-bundlereconstruction. For the purposes of preoperative planning, thesagittal thickness of the patellar and quadriceps tendons can bemeasured on magnetic resonance imaging (MRI) scans to pro-vide the surgeon with an idea as to potential graft size41. Studies
have also evaluated the use of MRI in predicting hamstring graftsize and have found that, while cross-sectional area measurementson MRI scans correlate positively with intraoperative graft size42,43,measurements of graft diameter do not42. Magnussen et al. foundthat a hamstring autograft size of8 mm in diameter was asso-ciated with a higher rate of early revision than were those of>8 mm44. In patients having primary surgery, allograft may beused when there are concerns of donor site morbidity or cos-mesis. Fresh-frozen allografts are typically preferred over ir-radiated, chemically processed, or preserved grafts and provideresults equal to those of autografts45-47. Recent studies have,however, indicated higher rates of graft failure following ACLreconstruction with varying types of allograft, particularly in
younger active individuals desiring an early return to sport48-51.Ultimately, daily activities and patient lifestyle influence
graft choice for an individual undergoing ACL reconstruction.For example, in a patient with daily activities that include kneeling(e.g., wrestling or religious practices), the use of a bone-patellartendon-bone autograft may be contraindicated because it is asso-ciated with a higher prevalence of anterior knee pain52.
Proper tunnel placement is critical in anatomic ACL re-construction. Nonanatomic tunnel placement has been previ-ously shown to decrease knee motion53 and to produce abnormalrotational knee kinematics during dynamic loading54. A recentstudy has evaluated the ACL tunnel positions used by twelve
surgeons and found a lack of agreement in the ideal position forsingle-bundle ACL tunnels55. Several intraoperative and post-operative methods have been described to evaluate tunnel place-ment. Postoperatively, anteroposterior and lateral radiographs
TABLE I Advantages and Disadvantages of Available Graft Choices for ACL Reconstruction
Graft Choice Advantages Disadvantages
Bone-patellar tendon-bone d Bone-to-bone healing in both tunnels d Not suitable for double-bundle reconstruction
d Comparable stiffness to native ACL d Risk of anterior kneeling pain
d Invasive, large incision
d Risk of patellar fracture
d Fixed length
d Weaker than native ACL
Hamstring d Ease of harvest d Soft-tissue healing
d Cosmesis d Graft size can be unpredictable
d Minimal donor site morbidity d Not suitable for certain athletes who rely
heavily on their hamstring musclesd Comparable strength to native ACL
d Less stiffness than native ACL
Quadriceps tendon d Large graft d Invasive, large incision
d Can be used for single or
double-bundle reconstruction
d Risk of patellar fracture
d Option of a one-sided bone block
Allograft d No donor site morbidity d Theoretical risk of disease transmission
d Available in various types and sizes d Longer healing time
d Increased risk of rerupture, especially in younger
patients and irradiated grafts
Fig. 2
A standard 45flexion weight-bearing posteroanterior (PA) radiograph,
made one year after single-bundle ACL reconstruction, demonstrating a
45 femoral tunnel angle relative to the long axis of the femur, suggestive
of anatomic tunnel placement41
.
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can be used to evaluate tunnel angle and implant position.Illingworth et al. described a femoral tunnel angle measure-ment based on the long axis of the femur on an anteroposteriorradiograph, whereby an angle of
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single-bundle reconstruction. The only significant difference inpatient-reported outcome was a higher Lysholm score in theanatomic double-bundle group in comparison with the con-ventional single-bundle group. There were no significant dif-ferences in patient-reported outcome scores in the comparisonof anatomic double-bundle with anatomic single-bundle recon-struction. In a second prospective comparative study (Level II),
anatomic single-bundle reconstructions were compared withanatomic double-bundle reconstructions with hamstring au-tograft, with the procedures individualized on the basis of in-traoperative measurements of the native ACL tibial insertionsite size65. At a mean follow-up of thirty months after surgery, nodifferences between the groups were detected with respect tothe Lysholm and IKDC Subjective Knee Form scores or the resultsof the KT-1000 measurements and pivot-shift tests.
The majority of published studies have shown no dif-ferences between anatomic single-bundle and double-bundle ACLreconstruction in terms of patient-reported outcomes. Differ-ences may exist with regard to knee joint laxity measurements,
favoring double-bundle reconstruction. There is also some evi-dence to suggest that individualized surgery may facilitate similaroutcomes with respect to knee joint laxity, regardless of whethersingle or double-bundle reconstruction is performed. Furtherinvestigation is needed to confirm or dispute these findings.
The outcomes after one-bundle augmentation reconstruc-tion for partial rupture of the ACL have been reported in severalseries. Sonnery-Cottet et al. reported that reconstruction of theanteromedial bundle with preservation of the posterolateral bundlesignificantly decreased anteroposterior laxity (Telos stress ra-diography), while significantly increasing the IKDC SubjectiveKnee Form and Lysholm scores at a mean follow-up of twenty-six months66. Adachi et al. compared ACL augmentation surgeryin partial ACL tears and complete ACL reconstruction with com-plete ACL tears at a mean follow-up of 2.6 years 67. The authorsreported augmentation surgery to be superior for joint stabil-ity and position sense. A recent systematic review found that
Fig. 4
Femoral and tibial three-dimensional CT reconstructions demonstrating
anatomic tunnel placement of a single-bundle ACL reconstruction.
Fig. 5
Femoral and tibial three-dimensional CT reconstructions demonstrating
anatomic tunnel placement of a double-bundle ACL reconstruction.
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the available evidence to support augmentation was weak butencouraging68.
In Vivo Biomechanics After ACL Reconstruction
In vivo kinematic studies evaluate knee biomechanics withoutthe time-zero limitation of in vitro studies. They also enableserial assessment of the effects of healing on knee function afterACL reconstruction and can involve realistic weight-bearingactivities, such as running, jumping, and stair-climbing.
Georgoulis et al. compared ACL-reconstructed and con-tralateral, normal knees using conventional video-motion analysiswith surface markers69. While no differences were evident during
walking, greater internal tibial rotation in the reconstructedknee was observed during more demanding pivoting tasks. Tashmanet al. used dynamic stereoradiography to assess knee kinematicsduring the stance phase of downhill running, and found greaterexternal rotation and adduction in ACL-reconstructed kneescompared with the contralateral, uninjured limbs54. The surgical
technique used for that study incorporated nonanatomic place-ment of the graft, demonstrating that nonanatomic ACL recon-struction fails to restore preinjury knee function under functionalloading conditions. Abebe et al. utilized biplanar fluoroscopyand MRI to evaluate knee function during a series of static jointpositions and reported that single-bundle reconstruction withanatomic femoral tunnel placement resulted in knee joint kine-matics that were more closely restored relative to the intact kneecompared with nonanatomic tunnel placement70.
In a separate study, tibiofemoral rotations and transla-tions in knees that had anatomic double-bundle ACL recon-struction were compared with those in the contralateral, normal
knees using a biplane radiographic system during the early tomidstance phase of running71. A model-based tracking methodwas also utilized to evaluate tibiofemoral kinematics. No sig-nificant or clinically important differences were found betweenthe ACL-reconstructed and contralateral limbs with regard tokinematic variables after anatomic double-bundle reconstruction.
Fig. 6
Figs.6-A and6-B Intraoperativearthroscopicphotographs demonstrating anatomic tunnelplacement forsingle-bundle ACL reconstructionon the femurand
tibia. Fig. 6-AA dilator is used to enlarge the tibial tunnel.Fig. 6-BA hamstring autograft is then tensioned and fixed in an anatomic position.
Fig. 7
Figs. 7-A and 7-BIntraoperative arthroscopic photographs demonstrating anatomic tunnel placement for double-bundle ACL reconstruction on the femur
and tibia.Fig.7-A Dilators are usedto enlarge thetibial tunnels. Fig.7-B Theanteromedial (AM)and posterolateral(PL) bundles arethen tensionedand fixed
with allografts in anatomic positions.
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These results suggest that anatomic double-bundle reconstruc-tion may be effective for restoring knee function compared withthe uninjured side. It is not, however, known whether anatomicsingle-bundle reconstruction may produce results similar to an-atomic double-bundle reconstruction compared with the con-tralateral knee.
Return to Sports After ACL Reconstruction
The timing of return to sports after ACL reconstruction is mul-tifactorial. Graft choice is an important consideration with re-gard to whether there is bone-to-bone healing (bone-patellartendon-bone graft) or soft tissue-to-bone healing. In a systematicreview and meta-analysis, Ardern et al. assessed forty-eight studieswith a total of 5770 patients at a mean follow-up of 41.5 monthsafter ACL reconstruction72. In total, while 82% of the patientsreported returning to some level of sporting activity, 63% of thepatients returned to sports participation at the preinjury level,and only 44% returned to competitive sports. The leading reason
given for not returning to sporting activity was fear of reinjury.Brophy et al. evaluated the return to sports among soccer
athletes and found that younger or male athletes were more likelyto return to play than were older or female athletes73. Smith et al.,who separately evaluated the return to the preinjury activity levelamong seventy-seven competitive athletes with a mean age oftwenty-one years (range, fifteen to thirty years), found that 71%(fifty-five) returned to preinjury activity levels by twelve monthsafter surgery74. Further research on return to sports should eval-uate the rate of return to the preinjury activity in terms of the type,frequency, intensity, and duration of participation.
Graft Failure After ACL Reconstruction
Graft failure in the ipsilateral knee after ACL reconstruction andnative ACL rupture in the contralateral knee have been inves-tigated. A recent study from the Danish Knee Ligament Recon-struction Register compared anteromedial with transtibial femoraltunnel drilling during ACL reconstruction. Anteromedial dril-ling had a higher overall rate of revision surgery (5.16%) thantranstibial drilling (3.20%), with a relative risk of 2.04 (95% con-fidenceinterval, 1.39 to 2.99)75. Surgeons should use caution whenevaluating these results, given the tendency of the transtibialtechnique to place the graft in a nonanatomic position. Indi-viduals undergoing anatomic ACL reconstruction may be at higherrisk for graft failure, particularly with early return to activity,given the higher, closer to normal, in situ forces on an anatomi-
cally placed graft76,77.A recent study by Bourke et al. of patients undergoing ACL
reconstruction with either bone-patellar tendon-bone or ham-string autograft found graft failure to be 11%, while contralateralACL rupture was 13%78. Graft choice did not affect failure rate.Other authors have also reported a higher risk of failure in thecontralateral ACL compared with the ipsilateral graft79. Shelbourneet al. followed 1415 patients for a minimum of five years afterACL reconstruction with bone-patellar tendon-bone autograftand found a lower patient age and higher activity level to beassociated with increased injury to either knee80. Returningto activity before six months postoperatively did not appear to
increase the risk for injury. In this particular study, the groupwith an age of less than eighteen years returned at a mean 4.6months after surgery. In a prospective analysis of failure inanatomic ACL reconstruction with allograft, van Eck et al. foundthat 48% (thirteen) of twenty-seven reruptures occurred withinnine months after surgery, before the patients had receivedclearance to return to sports51. Further investigation is requiredto determine factors affecting ACL graft failure, includingconsideration for graft healing. On the basis of the availableevidence, a lower patient age and higher activity level, but nottime to return to sport, appear to be predictive of reinjury.
Osteoarthritis After ACL Reconstruction
The development of osteoarthritis after ACL reconstruction is aconcern. Li et al. retrospectively investigated the predictors ofradiographic knee osteoarthritis after nonanatomic single-bundleACL reconstruction81. Radiographic osteoarthritis, defined as Kellgrenand Lawrence grade-2 changes in at least one compartment or
grade-1 changes in at least two compartments, were demonstratedby 39% (ninety-six) of 249 patients at a mean 7.86 years follow-up. The most optimal set of predictors for osteoarthritis werebody mass index, length of follow-up, prior medial meniscectomy,and medial chondrosis of grade 2 or greater. Separately, Roeet al. investigated differences in osteoarthritis rates in a consec-utive cohort of nonrandomized patients who underwent ACLreconstruction with hamstring or bone-patellar tendon-boneautograft82. At seven years of follow-up, 45% (twenty-four) of fifty-three patients in the bone-patellar tendon-bone group and 14%(seven) of fifty-one in the hamstring group showed signs of ra-diographic osteoarthritis (p =0.002).
Several studies with longer-term follow-up have also been
performed. Oiestad et al. prospectively evaluated knee functionand the prevalence of osteoarthritis in patients ten to fifteen
years after isolated ACL reconstruction and in patients who hadconcomitant meniscal and/or cartilage pathology83. Radiographicassessment using the Kellgren and Lawrence classification systemrevealed that 80% of the patients in the concomitant pathologygroup had joint space narrowing of grade 2 or greater comparedwith 62% in the isolated group (p = 0.008). However, differenceswere not detectable between groups with respect to symptomaticosteoarthritis. In a separate study of the same cohort, Oiestad et al.reported that the prevalence of patellofemoral osteoarthritis was26.5%(forty-eight of 181 patientstwelve years after reconstruction)and was associated with older age, increased symptoms, and greater
tibiofemoral osteoarthritis, as well as reduced knee function84.Salmon et al. also reported an association between de-
generative joint changes and meniscectomy, increased kneejoint laxity, and loss of knee motion thirteen years after ACLreconstruction with bone-patellar tendon-bone autograft85. Sim-ilarly, Shelbourne et al. evaluated 780 patients undergoing ACLreconstruction with bone-patellar tendon-bone autograft and,at a minimum of five years of follow-up, found that the loss ofnormal knee flexionandextension wasassociated with an increasedrate of radiographic osteoarthritis86. In two separate studies ofpatients in whom concomitant knee pathology was absent atthe time of surgery, Shelbourne and Gray and Lebel et al. reported
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that the rate of osteoarthritis was 2% and 8%, respectively, beyondthe mean follow-up time of ten years87,88.
It is the general consensus of the available evidence thatmeniscal and/or cartilage damage and knee motion deficits aftersurgery are associated with the development and/or progres-sion of osteoarthritis after ACL reconstruction. Furthermore,patients without concomitant joint pathology at the time ofACL surgery appear to have a low rate of osteoarthritis, even atrelatively long-term follow-up. Continued investigation into thecause and development of osteoarthritis after ACL reconstruction,
including early recognition via advanced imaging modalities oridentification of relevant biomarkers, will be important.
In conclusion, operative management of acute ACL ruptureis common in young and active patients and can achieve pre-dictable outcomes (Table II). The use of double-bundle re-construction appears to provide no difference compared withsingle-bundle reconstruction in patient-reported outcomes. Theage and activity level of the patient are predictive of the return tosports and of reinjury. On the basis of the currently availabledata, the time to return to sports may not be predictive of reinjuryto the reconstructed ACL. Meniscal and/or cartilage pathologynoted at the time of ACL reconstruction, as well as a knee motiondeficit postoperatively, are associated with the developmentand/or progression of osteoarthritis. Future studies investigatingoperative methods for the treatment of ACL injuries are war-ranted. It is imperative that these studies be adequately poweredand use patient-relevant and sensitive outcome measures. n
Christopher D. Murawski, BSCarola F. van Eck, MD, PhDJames J. Irrgang, PT, PhD, ATC, FAPTAScott Tashman, PhDFreddie H. Fu, MD, DSc(Hon), DPs(Hon)Department of Orthopaedic Surgery,University of Pittsburgh School of Medicine,3471 Fifth Avenue, Suite 1011,Pittsburgh, PA 15213.E-mail address for F.H. Fu: ffu@upmc.edu.
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TABLE II Grades of Recommendation for Operative Treatment of
Primary Anterior Cruciate Ligament Rupture in Adults
Recommendation Grade of Evi dence*
Operative treatment B
Single-bundle reconstruction C
Double-bundle reconstruction C
Autograft C
Allograft C
*Grade A indicates good evidence (Level-I studies with consistentfindings) for or against recommending the intervention; Grade B,fair evidence (Level-II or III studies with consistent findings) for oragainst recommending the intervention; Grade C, conflicting orpoor-quality evidence (Level-IV or V studies) not allowing a rec-ommendation for or against the intervention; and Grade I, there isinsufficient evidence to make a recommendation
89.
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23. Markolf KL, Park S, Jackson SR, McAllister DR. Anterior-posterior and rotatorystabilityof single anddouble-bundle anteriorcruciateligament reconstructions.J BoneJoint Surg Am. 2009 Jan;91(1):107-18.
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63. Tiamklang T, Sumanont S, Foocharoen T, Laopaiboon M. Double-bundle versussingle-bundle reconstruction for anterior cruciate ligament rupture in adults. Co-chrane Database Syst Rev. 2012;11:CD008413. Epub 2012 Nov 14.
64. Hussein M, van Eck CF, Cretnik A, Dinevski D, Fu FH. Prospective randomizedclinical evaluation of conventional single-bundle, anatomic single-bundle, and ana-tomic double-bundle anterior cruciate ligament reconstruction: 281 cases with 3- to5-year follow-up. Am J Sports Med. 2012 Mar;40(3):512-20. Epub 2011 Nov 15.
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66. Sonnery-Cottet B, Panisset JC, Colombet P, Cucurulo T, Graveleau N, Hulet C,Potel JF, Servien E, Trojani C, Djian P, Pujol N; French Arthroscopy Society (SFA).Partial ACL reconstruction with preservation of the posterolateral bundle. OrthopTraumatol Surg Res. 2012 Dec;98(8)(Suppl):S165-70. Epub 2012 Nov 08.
67. Adachi N, Ochi M, Uchio Y, Sumen Y. Anterior cruciate ligament augmentationunder arthroscopy. A minimum 2-year follow-up in 40 patients. Arch Orthop TraumaSurg. 2000;120(3-4):128-33.
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journal of orthopaedic&sports physical therapy | volume 42 | number 11 | november 2012 | 893
[RESEARCHREPORT]
Anterior cruciate ligament
(ACL) injuries commonlyoccur during sports-
related activities thatrequire cutting and pivoting, with
over 200 000 injuries reportedin the United States each year.23
Most individuals elect to undergo surgi-
cal reconstruction following injury to re-
store knee function and facilitate return
to sports participation.51,56Although ACL
reconstruction is thought to provide the
athlete with the best opportunity to re-
turn to preinjury levels of sports partici-
pation,33recent studies1,2,21,30,38,57reported
that between 8% and 50% of those with
ACL reconstruction did not return to thesame sports after surgery, even with fol-
low-up times of up to 5 years.31 Moreover,
as many as 70% of individuals previously
involved in contact sports were unable
to return to the same sports after sur-
STUDY DESIGN:Cross-sectional cohort.
OBJECTIVES:(1) To examine differences in
clinical variables (demographics, knee impair-
ments, and self-report measures) between those
who return to preinjury level of sports participation
and those who do not at 1 year following anterior
cruciate ligament reconstruction, (2) to deter-
mine the factors most strongly associated with
return-to-sport status in a multivariate model, and
(3) to explore the discriminatory value of clinical
variables associated with return to sport at 1 year
postsurgery.
BACKGROUND:Demographic, physical impair-
ment, and psychosocial factors individually prohibit
return to preinjury levels of sports participation.
However, it is unknown which combination
of factors contributes to sports participation status.
METHODS:Ninety-four patients (60 men; mean
age, 22.4 years) 1 year postanterior cruciate liga-
ment reconstruction were included. Clinical vari-
ables were collected and included demographics,
knee impairment measures, and self-report ques-
tionnaire responses. Patients were divided into yes
return to sports or no return to sports groups
based on their answer to the question, Have you
returned to the same level of sports as beforeyour injury? Group differences in demographics,
knee impairments, and self-report questionnaire
responses were analyzed. Discriminant function
analysis determined the strongest predictors of
group classification. Receiver-operating-char-
acteristic curves determined the discriminatory
accuracy of the identified clinical variables.
RESULTS:Fifty-two of 94 patients (55%) report-
ed yes return to sports. Patients reporting return to
preinjury levels of sports participation were more
likely to have had less knee joint effusion, fewer epi-
sodes of knee instability, lower knee pain intensity,
higher quadriceps peak torque-body weight ratio,
higher score on the International Knee Documenta-
tion Committee Subjective Knee Evaluation Form,
and lower levels of kinesiophobia. Knee joint
effusion, episodes of knee instability, and score on
the International Knee Documentation CommitteeSubjective Knee Evaluation Form were identi-
fied as the factors most strongly associated with
self-reported return-to-sport status. The highest
positive likelihood ratio for the yes-return-to-sports
group classification (14.54) was achieved when
patients met all of the following criteria: no knee ef-
fusion, no episodes of instability, and International
Knee Documentation Committee Subjective Knee
Evaluation Form score greater than 93.
CONCLUSION:In multivariate analysis, the fac-
tors most strongly associated with return-to-sport
status included only self-reported knee function,
episodes of knee instability, and knee joint effusion.
LEVEL OF EVIDENCE:Prognosis, level 2b.J Orthop Sports Phys Ther 2012;42(11):893-901,
Epub 2 August 2012. doi:10.2519/jospt.2012.4077
KEY WORDS:ACL, kinesiophobia, return to
sports
1Staff Physical Therapist, Shands Rehab Center, University of Florida Orthopaedics and Sports Medicine Institute, Gainesville, FL. 2Clinical Coordinator, Shands Rehab Center, University of
Florida Orthopaedics and Sports Medicine Institute, Gainesville, FL. 3Orthopaedic Surgeon, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL. 4Associate
Professor and Assistant Department Chair, Department of Physical Therapy, University of Florida, Gainesville, FL. 5Associate Professor, Department of Physical Therapy, University of Florida,
Gainesville, FL. Dr Chmielewskis effort on this project was supported by a grant from the National Institutes of Health (K01-HD052713) and by the National Center for Medical Rehabilitation
Research. This project was reviewed and approved by the Institutional Review Board at the Unive rsity of Florida. Address correspondence to Trevor Lentz, Shands Rehab Center, University of
Florida Orthopaedics and Sports Medicine Institute, 3450 Hull Road, Gainesville, FL 32611. E-mail: lentzt@shands.ufl.eduCopyright 2012 Journal of Orthopaedic & Sports Physical Therapy
TREVOR A. LENTZ, PT1 GIORGIO ZEPPIERI, JR., PT1 SUSAN M. TILLMAN, PT2 PETER A. INDELICATO, MD3
MICHAEL W. MOSER, MD3 STEVEN Z. GEORGE, PT, PhD4 TERESE L. CHMIELEWSKI, PT, PhD5
Return to Preinjury Sports ParticipationFollowing Anterior Cruciate LigamentReconstruction: Contributions
of Demographic, Knee Impairment,and Self-report Measures
Copyright2012JournalofOrthopaedic&S
po
rtsPhysicalTherapy.Allrightsreserved.
mailto:lentzt@shands.ufl.edumailto:lentzt@shands.ufl.edumailto:lentzt@shands.ufl.edu -
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894 | november 2012 | volume 42 | number 11 | journal of orthopaedic&sports physical therapy
[RESEARCHREPORT]
gery.47Of those individuals who did re-
turn to their prior sports, up to 21% were
reported to have returned with major
functional limitations that contributed to
a reduced level of performance.49For ex-ample, a study of running backs and wide
receivers in the National Football League
found that almost 80% returned to com-
petition after ACL injury, but player per-
formance, measured by power ratings,
was reduced by one-third.10 Moreover,
22% of the athletes with ACL recon-
struction in the National Basketball As-
sociation did not return to a sanctioned
National Basketball Association game af-
ter surgery and, of those who did return,
44% experienced a decrease in standardstatistical categories and player efficiency
ratings.9 It has been suggested that the
high incidence of poor return-to-sport
outcomes following ACL reconstruction
may be due to a lack of standardized re-
turn-to-sport guidelines and incomplete
resolution of physical and psychological
impairments.3,32,36,37
Poor understanding of the important
factors that determine a successful return
to sports has contributed to variability in
return-to-sport criteria.4,29
Many crite-ria have been developed based on expert
opinion, empirical evidence, or factors
identified as contributors to postop-
erative self-reported disability following
ACL reconstruction, including number
of injured knee structures,48 quadriceps
strength,32,45,58 knee pain intensity,32,58
knee flexion range of motion (ROM),32
single-leg hop performance,48,55,58 and
pain-related fear of movement/reinju-
ry.11,30-32Although these factors have been
associated with self-reported knee func-tion, it is unclear if they influence return
to preinjury levels of sports participation
following ACL reconstruction. Further-
more, the relative importance of these
factors is unknown. To our knowledge,
no study to date has examined demo-
graphic, knee impairment, and psycho-
social measures in a multivariate model
to determine the most important factors
associated with return to preinjury levels
of sports participation.
Understanding differences between
individuals who do or do not return to
sport after ACL reconstruction is the next
step toward developing evidence-based
return-to-sport rehabilitation guidelinesand participation criteria. The purposes
of this study were (1) to examine differ-
ences in clinical variables (demograph-
ics, knee impairments, and self-report
measures) between those who return to
preinjury level of sports participation
and those who do not at 1 year following
ACL reconstruction, (2) to determine
the factors most strongly associated with
return-to-sport status in a multivariate
model, and (3) to explore the discrimina-
tory value of clinical variables associatedwith return to sport at 1 year postsur-
gery. Based on previous literature, we
hypothesized that a combination of de-
mographic, knee impairment, functional,
and psychosocial measures would differ
and discriminate between those who did
and did not return to sports.
METHODS
Patients
Consecutive patients with ACLreconstruction seen for routine
physician follow-up at 1 year post-
surgery at the University of Florida
Orthopaedics and Sports Medicine In-
stitute, Gainesville, FL, were eligible to
participate. Patients were enrolled over a
3-year period between September 2007
and September 2010. Inclusion criteria
were (1) unilateral arthroscopic ACL
reconstruction, (2) age between 15 and
50 years, (3) time from injury to sur-
gery of 12 months or less, and (4) prein-jury score of 5 or greater on the Tegner
activity-level scale. Our age group was
chosen to include individuals most likely
to be involved in sports-related activities
and undergo ACL reconstruction follow-
ing ACL injury. We specified a preinjury
Tegner activity level of at least 5 to target
a population of patients who were, at a
minimum, involved in recreational sports
prior to injury. Potential patients were ex-
cluded if they had (1) bilateral knee in-
jury, (2) prior knee ligament injury and/
or surgery, (3) concomitant ligamentous
injury greater than grade I, (4) articular
cartilage repair procedure performed in
conjunction with ACL reconstruction, or(5) inability to return to sports following
surgery due to social reasons (too little
time to participate in sports or a change
in lifestyle).31In communities with a high
prevalence of college students, such as the
one from which the present sample was
drawn, it has been observed that some
individuals choose not to return to sport
due to too little time to participate in
sports or to a change in lifestyle (they at-
tend graduate school, graduate, get a job,
start a family, etc). As a result, many ofthese individuals may not have the moti-
vation or potential to return to sport due
to influences other than their physical or
psychological capabilities. Other exclu-
sion criteria were chosen because they
represent additional injuries or surgical
procedures that may significantly affect
the course of rehabilitation or functional
outcome.48Patients provided written in-
formed consent, and the protocol for the
study was approved by the University of
Florida Institutional Review Board.
Surgical Procedure and Rehabilitation
Program
All surgical procedures were performed
arthroscopically by a board-certified or-
thopaedic surgeon (P.A.I. or M.W.M.),
using autograft or allograft tissue. The
autograft sources were bone-patellar
tendon-bone or semitendinosus and
gracilis tendons. The allograft sources
were tibialis anterior, tibialis posterior, or
Achilles tendon. The surgical procedure,as well as graft selection process, for our
surgeons has been previously published.13
Rehabilitation was not controlled in this
study; however, the standard ACL recon-
struction rehabilitation protocol used in
our facility and given to patients under-
going rehabilitation at outside facilities
allows for immediate weight bearing and
knee motion as tolerated. The empha-
sis of the first 6 weeks of rehabilitation
is on decreasing knee effusion, develop-
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ing quadriceps control, and regaining
full knee motion. The next 6 weeks of
rehabilitation are focused on increasing
lower extremity muscle strength, muscle
endurance, and neuromuscular control.Straight-ahead running is permitted at
12 weeks if (1) quadriceps strength sym-
metry index is greater than 60%, (2) knee
effusion is trace or less, (3) knee exten-
sion ROM is equal to the contralateral
side, (4) knee flexion ROM is within 5
of the contralateral side, and (5) aver-
age knee pain is less than 2/10. Agility
exercises are initiated at 18 weeks post-
surgery following successful completion
of a straight-ahead running program.
Patients are allowed to return to sportwhen the following criteria are met: (1)
knee ROM equal to the contralateral side,
(2) quadriceps strength greater than 85%
of the opposite knee based on isokinetic
testing, (3) no knee effusion, and (4)
completion of an agility and sport-spe-
cific program. These criteria are typically
met around 6 months postsurgery.
Testing Overview
Patients were tested at a routine 1-year
clinical follow-up visit. A standardizedtesting protocol consisted of the collec-
tion of demographic information, knee
impairment measures, and self-report
questionnaire responses. Testers were
physical therapists with an average of
10.3 years (range, 5-17 years) of experi-
ence in sports physical therapy. Data
were recorded on standard forms and
entered into an electronic database (Mi-
crosoft Access 2007; Microsoft Corpora-
tion, Redmond, WA).
Demographic Information
Demographic information included age,
sex, weight, time from injury to surgery,
graft type (autograft or allograft), con-
comitant knee injuries, and time from
surgery to follow-up. Concomitant inju-
ries were diagnosed during the preop-
erative physician evaluation or during
surgery, and included meniscal injuries,
chondral lesions, and collateral ligament
injuries.
Knee Impairment Measures
Knee Effusion Knee effusion was as-
sessed with the stroke test and graded on
a 5-point scale (none, trace, 1+, 2+, and
3+).50This method of assessing knee effu-sion has a substantial interrater reliabil-
ity (= 0.75).50
Knee ROM Knee flexion and extension
passive ROM were measured in both
the nonsurgical and surgical sides us-
ing a standard goniometer. Side-to-side
knee flexion and extension ROM deficits
were calculated (nonsurgical-side ROM
minus surgical-side ROM). Intertester
reliability has been shown to be high for
measurements of knee flexion ROM (in-
traclass correlation coefficient [ICC] =0.98) and knee extension ROM (ICC =
0.89-0.93) using a standard goniometer.8
Knee Ligament Laxity Testing To assess
the integrity of the ACL graft, anterior
displacement of the tibia was measured
with a KT1000 knee ligament arthrome-
ter (MEDmetric Corporation, San Diego,
CA). The tibia was pulled to the end point
of anterior translation while the knee was
flexed to approximately 30. The amount
of anterior displacement was recorded in
millimeters. Two trials were performedon each side and averaged. The differ-
ence in values between the surgical and
nonsurgical sides was recorded as the
anterior knee joint laxity difference. The
KT1000 has been shown to provide val-
id44,46and reliable measurements of ante-
rior knee joint laxity (ICC = 0.91-0.93).7
Quadriceps Strength Testing Knee ex-
tensor (quadriceps) strength was as-
sessed with an isokinetic dynamometer
(Biodex System 3; Biodex Medical Sys-
tems, Shirley, NY). Prior to testing, pa-tients were given a 5-minute warm-up
on a stationary bicycle. They were then
seated and stabilized with a lap-and-
thigh belt. The dynamometer arm was
set to move through a range of 90 to 0
of knee motion at a speed of 60/s. Test-
ing was conducted on the nonsurgical
side first. Patients performed 2 practice
trials followed by 5 maximal-effort trials.
Testing was then repeated on the surgi-
cal side. The peak knee extensor torque
of 5 trials was recorded for each side. Two
separate measures of quadriceps muscle
performance were calculated. First, a
quadriceps symmetry index was calcu-
lated by normalizing the peak knee ex-tensor torque on the surgical side to that
of the nonsurgical side and multiplying
by 100. Second, the knee extensor torque-
body weight ratio was calculated by di-
viding knee extensor peak torque (ftlb)
of the surgical side by the subjects body
weight (lb). Isokinetic strength testing
has been shown to be a reliable meth-
od of quadriceps strength testing (ICC
= 0.81-0.97)7 and sensitive to strength
changes in the first 2 years following ACL
reconstruction.45
Self-report Questionnaires
Tegner Activity-Level Scale The Tegner
activity-level scale is an 11-point grad-
ing scale for work and sports activities.52
The scale rates activity level from 0 (sick
leave or disability pension because of
knee problems) to 10 (competitive sports
such as soccer, football, or rugby at the
national or elite level). Level 5 indicates
participation in sport-related activities
at the lowest recreational level. The scalewas initially developed to measure activ-
ity following knee ligamentous injury and
has been validated for use following ACL
injury.6The Tegner scale has demonstrat-
ed acceptable test-retest reliability (ICC
= 0.80) after ACL reconstruction.6At the
time of follow-up testing, patients were
asked to rate their current level of sports
participation as well as to recall their pre-
injury level of sports participation.
Knee Pain Intensity Knee pain inten-
sity was assessed with an 11-point visualnumeric rating scale. Pain intensity rat-
ings ranged from 0 (no pain) to 10 (worst
imaginable pain). Patients were asked
to rate their worst and best pain levels
over the past 24 hours. They were also
asked to rate their current level of pain.
All 3 pain ratings were averaged to get a
composite knee pain intensity score. The
numeric rating scale has been shown to
be a reliable method of pain intensity as-
sessment (ICC = 0.74-0.76).14,34
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Episodes of Knee Instability Patients
were asked, How many episodes of giv-
ing way or buckling at the knee have
occurred since your surgery? Possible
answers included 0, 1, 2 to 5, and greaterthan 5.
Tampa Scale for Kinesiophobia Kine-
siophobia, or fear of movement/reinjury,
was measured with the shortened version
of the Tampa Scale for Kinesiophobia
(TSK-11).59 Response items are related
to somatic sensations (eg, Pain always
means I have injured my body) and
activity avoidance (eg, Im afraid that I
might injure myself if I exercise). Scores
on the TSK-11 range from 11 to 44 points,
with higher scores indicating greaterpain-related fear of movement/reinjury.
Good test-retest reliability (ICC = 0.81
and 0.93)20,59has been reported for the
TSK-11 in patients with chronic low back
pain. The TSK-11 is a psychometrically
stable instrument to assess fear of move-
ment/reinjury in the later stages of reha-
bilitation following ACL reconstruction.19
International Knee Documentation
Committee Subjective Knee Evaluation
Form Knee function was measured with
the International Knee DocumentationCommittee Subjective Knee Evalua-
tion Form (IKDC). The IKDC contains
10 items related to knee symptoms and
physical function.26Scores range from 0
to 100, with higher scores indicating less
disability. An ICC of 0.94 and a standard-
ized response mean of 0.94 have been re-
ported for the IKDC across a broad range
of knee pathologies, including ACL injury
and ACL reconstruction.26,27
Return-to-Sport Status All patients were
asked 2 questions regarding their return-to-sport status: (1) Have you returned to
sports or recreational activities since your
surgery? and (2) Have you returned to
the same level of sports as before your in-
jury? Because our purpose was to specif-
ically examine return to preinjury levels
of sports participation, patients were di-
vided into return-to-sport-status groups
based on their answer to the question,
Have you returned to the same level of
sports as before your injury? Those who
indicated that they had returned to the
same level of preinjury sports participa-
tion were designated Y-RTS (yes return to
sports), and those who reported that they
had not returned to the same level were
designated N-RTS (no return to sports).
Patients who reported that they had not
returned to preinjury levels of sports
participation were asked to pick their
primary reason for not having returned
from a list of options that included pain,
swelling, fear of injury or lack of confi-dence, knee instability, muscle weakness,
not yet cleared from doctor to return to
sports, too little time to participate or had
a change in lifestyle, and other. This an-
swer represented the subjects perceived
reason for not being able to return to the
preinjury level of sports participation.
Statistical AnalysisStatistical analyses were conducted with
SPSS for Windows Version 13.0 (SPSS
Inc, Chicago, IL). Descriptive statistics
were generated for all variables. We ana-
lyzed the data in the following steps: (1)
identification of clinical factors that dif-
fered between groups based on return-
to-sport status, (2) determination of the
factors most strongly associated with
return-to-sport status in a multivariate
model, and (3) testing the discrimina-
tory value of clinical variables associated
with return-to-sport group allocation. An
alpha level of .05 was used for inferentialanalyses.
For the first step, independent-sam-
ples ttests determined group differences
(Y-RTS versus N-RTS) in continuous
variables, and chi-square tests were used
for categorical variables. If any individu-
al cells were below 5, we used the Fisher
exact test instead of chi-square analysis.
A 2-way repeated-measures analysis of
variance was used to analyze preinjury-
to-postsurgical changes in Tegner score
TABLE 1Demographic Variable Means and
Distributions for Y-RTS and N-RTS Groups*
Abbreviations: N-RTS, patients indicating they had not returned to preinjury levels of sports partici-
pation; Y-RTS, patients indicating they had returned to preinjury levels of sports participation.
*Values are meanSD.Significance of difference between Y-RTS and N-RTS group means.
Measure Y-RTS (n = 52) N-RTS (n = 42) Total (n = 94) PValue
Injury to surgery, d 70.656.6 80.466.5 75.061.0 .44
Preinjury Tegner score 8.41.6 8.31.6 8.41.5 .76
Postsurgical Tegner score 8.31.6 6.61.8 7.51.9
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journal of orthopaedic &sports physical therapy | volume 42 | number 11 | november 2012 | 897
between groups based on return-to-sport
status.
For the second step, discriminant
function analysis (DFA) was performed
to investigate which of the factors identi-fied by comparative analysis in the first
step were predictors of group status in a
multivariate model. To avoid excluding
any potentially discriminating factors, a
liberal statistical criterion (P.15) was
used to determine factors that would be
entered into the DFA. Briefly, DFA is a
technique that classifies variables into
separate functions based on how linear
combinations of the variables predict
differences in functions. In this analysis,
DFA was used to identify a parsimoni-
ous set of variables that contributed to
determining a function. Specifically, we
were interested in including variables in
the prediction model with standardizedcoefficients of 0.3 or greater in predicting
the derived functions.
For the third step, we tested the abil-
ity of the multivariate model identified
by DFA to discriminate between return-
to-sport status groups. An a priori deci-
sion was made to use receiver operating
characteristic (ROC) curve analyses from
prior unpublished pilot data to determine
the cutoff value for each continuous and
categorical clinical variable that best dif-
ferentiated the 2 return-to-sport outcome
groups.
For statistical analysis, values on the
more favorable side of the cutoff score for
each variable were coded as 1, and the lessfavorable values were coded as 0. Group
allocation for return-to-sport outcome
was coded as 1 for Y-RTS and 0 for N-
RTS. The number of criteria met for the
multivariate model was determined for
each subject. The accuracy of this model
was then determined by computing posi-
tive and negative likelihood ratios.
RESULTS
Atotal of 94 patients were in-cluded in the study (60 men, 34
women; mean SD age, 22.4
8.6 years). Demographic information
for these patients is presented in TABLE 1.
Eighty-six patients (91%) reported they
had returned to some form of sports or
recreational activity since their surgery;
however, only 52 (55%) reported return-
ing to preinjury levels of sports partici-
pation, and these were included in the
Y-RTS group. Forty-two patients (45%)
reported they had not returned to theirpreinjury level of sports participation
and were included in the N-RTS group.
Of those patients reporting N-RTS, 45%
(19/42) reported fear of reinjury/lack of
confidence as a primary reason for not
returning to preinjury levels of sports
participation, and knee joint symptoms
(pain, swelling, instability, muscle weak-
ness) collectively accounted for an addi-
tional 40% (17/42). Pain (5/42 [12%])
and muscle weakness (5/42 [12%]) were
the most frequently reported knee jointsymptoms. The distributions of primary
reasons for not returning to preinjury
sports participation are presented in
TABLE 2.
Group differences in demographics,
knee impairments, and self-report ques-
tionnaire scores are presented in TABLE 3.
There was no significant difference in age
between groups (P= .07). Tegner activity-
level scores decreased from preinjury to
follow-up in both groups; however, this
TABLE 3
Means and Group Differences
for Demographic, Knee Impairment,
and Self-report Variables*
Abbreviations: IKDC, International Knee Documentation Committee Subjective Knee Evaluation
Form (0-100); N-RTS, patients indicating they had not returned to preinjury levels of sports partici-
pation; ROM, range of motion; TSK-11, shortened version of Tampa Scale for Kinesiophobia (11-44);
Y-RTS, patients indicating they had returned to preinjury levels of sports participation.
*Data are meanSD unless otherwise indicated.The postsurgical follow-up Tegner score minus the preinjury Tegner score.Fisher exact test analysis.
Measure Y-RTS (n = 52) N-RTS (n = 42) PValue
Age, y 20.98.3 24.28.8 .066
Tegner change score 0.10.4 1.91.6
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[RESEARCHREPORT]
decrease was found to be statistically sig-
nificant in the N-RTS group only. Patients
in the Y-RTS group had less presurgical-
to-postsurgical change in Tegner score
(P
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jury,43and it is commonly suggested that
these asymmetries should be resolved
prior to initiation of sports activities.36,41,42
Although some variables previously
associated with function following ACLreconstruction, such as knee pain inten-
sity,32,58fear of movement/reinjury,11,30-32
and quadriceps strength,32,45,58 had bi-
variate associations with return to pre-
injury sport participation, they were not
retained in multivariate analysis. Perhaps
the most unexpected finding was the ex-
clusion of fear of movement/reinjury
from the model, because this has been
strongly associated with return to sports
participation in prior studies29,31and was
the most prevalent reason cited for notreturning to sport in our sample. Some
authors have speculated that psychoso-
cial factors, such as fear of movement/
reinjury, may help to explain the discrep-
ancy between generally favorable knee
scores and poor return-to-sport rates
following surgery.2,3 It is plausible that
fear of movement/reinjury may mediate
the relationship between activity restric-
tions and factors included in the model
(ie, instability or self-reported function),
yet not be identified as a significant in-dividual factor in multivariate analysis.
Thus, concurrent assessment of pain-
related fear of movement/reinjury and
clinical measures may be unnecessary for
prediction of return-to-sport status, be-
cause no further variance was explained
by inclusion of this construct in the mul-
tivariate model.
A strength of this study is that it is
the first, to our knowledge, to study the
contributions of demographic, knee im-
pairment, and psychosocial factors in amultivariate analysis for the determina-
tion of return-to-sport status at 1 year
postsurgery. This is an important step
toward creating evidence to guide the
development of rehabilitation programs
and return-to-sport criteria to improve
outcomes following ACL reconstruc-
tion. There are several limitations of this
study to consider when interpreting the
results. This is a cross-sectional design;
therefore, it remains to be proven if the
variables identified in this study will lon-
gitudinally predict return-to-sport status
at 1 year postsurgery. One year is gener-
ally considered a short follow-up period
after ACL reconstruction; however, it hasbeen shown that, of those patients who
return to sports, most do so within the
first year.49Furthermore, although most
patients were released to return to sport
at 6 months postsurgery, data on the tim-
ing of return to sport for each individual
patient were not collected or analyzed.
Therefore, some patients might have had
more or less time to be exposed to sport
activities than others, which should be
considered when interpreting the results.
The results of our study may not beapplied universally to all patients follow-
ing ACL reconstruction. Patient status
as a coper or noncoper was not assessed,
and it is plausible that different factors
underlie functional recovery between
these groups.17,24 Our exclusion criteria
omitted those patients with concomitant
ligamentous and articular cartilage dam-
age requiring surgical procedures. Fur-
thermore, patients who did not return for
surgeon follow-up at 1 year postsurgery
were not tested. This inherent selectionbias should be considered when inter-
preting these results.
A final limitation of our study is the
use of a nonvalidated self-report mea-
sure of return to sports participation.
Most studies utilize self-report-of-func-
tion questionnaires that measure knee
performance across a wide spectrum of
constructs,11,31,32,45,48,58 and comparisons
are not often drawn between the abil-
ity to return to preinjury levels of sports
participation and the ability to return tosports, even at a reduced level.54Objec-
tive clinical comparison of preinjury to
postsurgery levels of sports participation
or performance also has its limitations
due to variable measurements of profes-
sional, amateur, and recreational athletic
performance across sports. Although our
methodology has not been validated, it
has the potential to provide a more accu-
rate estimation of sport-related function
compared to preinjury levels.
Future studies should test the longitu-
dinal validity of this model for prediction
of return-to-sport status, as well as exam-
ine other potentially important physical
performance measures, impairment vari-ables, and psychological barriers related
to return to sport. This study only exam-
ined 1 psychosocial construct directly,
and it is possible that other psychosocial
factors may contribute more significantly
to function in multivariate models.15,60
One such factor, self-efficacy, has been
shown to be a preoperative predictor of
outcome 1 year after ACL reconstruc-
tion,53and is predictive of improvements
in knee pain intensity and self-reported
function in the first 12 weeks followingsurgery.12Future studies should examine
the relationship of fear of movement/re-
injury and other psychosocial constructs,
such as self-efficacy, longitudinally and
at follow-up times longer than 1 year to
determine which constructs best predict
return-to-sport status.
CONCLUSION
T
his study provides further in-
sight into clinical variables thatempirically discriminate between
individuals in return-to-sport groups.
Results suggest that ongoing knee symp-
toms following ACL reconstruction are
associated with individuals returning
to preinjury sports participation levels.
These potentially modifiable factors rep-
resent important targets for rehabilita-
tion. Findings from this study should be
considered in future longitudinal studies
aimed at the development of return-to-
sport rehabilitation guidelines and par-ticipation criteria.
KEY POINTS
FINDINGS:Patients reporting return to
preinjury levels of sports participa-
tion had less knee joint effusion, fewer
episodes of knee instability, lower
knee pain intensity, higher quadriceps
peak torque-body weight ratio, higher
IKDC scores, and lower TSK-11 scores.
The strongest contributors to return-
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