return to sports after acl reconstruction jbjs_and__jospt_articles

8/10/2019 Return to Sports After ACL Reconstruction JBJS_and__JOSPT_articles

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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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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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O P E R A T I V E TR E A T M E N T O F P R I M A R YAN T E R I O R

C R U C I A T E L I G A M E N T RU P T U R E I N AD U L T S


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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: [email protected].

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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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36. Kopf S, Pombo MW, Szczodry M, Irrgang JJ, Fu FH. Size variability of the humananterior cruciate ligament insertion sites. Am J SportsMed. 2011 Jan;39(1):108-13.Epub 2010 Sep 16.

37. van Eck CF, Martins CA, Vyas SM, Celentano U, van Dijk CN, Fu FH. Femoralintercondylarnotchshapeand dimensions in ACL-injured patients. Knee Surg SportsTraumatol Arthrosc. 2010 Sep;18(9):1257-62.

38. Steiner ME, Hecker AT, Brown CH Jr, Hayes WC. Anterior cruciate ligament graftfixation. Comparison of hamstring and patellar tendon grafts. Am J Sports Med.1994 Mar-Apr;22(2):240-6; discussion 246-7.

39. B eynnon BD, Johnson RJ, Fleming BC, Kannus P, Kaplan M, Samani J, RenstromP. Anterior cruciate ligament replacement: comparison of bone-patellar tendon-bonegrafts with two-strand hamstring grafts. A prospective, randomized study. J Bone JointSurg Am. 2002 Sep;84(9):1503-13.

40. Adam F, Pape D,SchielK, SteimerO, Kohn D, Rupp S. Biomechanical propertiesof patellar and hamstring graft tibial fixation techniques in anterior cruciate ligamentreconstruction: experimentalstudy with roentgen stereometricanalysis. Am J SportsMed. 2004 Jan-Feb;32(1):71-8.

41. AraujoP, vanEck CF,Torabi M,Fu FH.Howto optimizethe useof MRI inanatomicACL reconstruction. KneeSurg Sports TraumatolArthrosc. 2013 Jul;21(7):1495-501.Epub 2012 Aug 15.

42. Beyzadeoglu T, Akgun U, Tasdelen N, Karahan M. Prediction of semitendinosusand gracilis autograft sizes for ACL reconstruction. Knee Surg Sports TraumatolArthrosc. 2012 Jul;20(7):1293-7. Epub 2011 Nov 25.

43. Wernecke G, Harris IA, Houang MT, Seeto BG, Chen DB, MacDessi SJ. Usingmagnetic resonance imaging to predict adequate graft diameters for autologoushamstring double-bundle anterior cruciate ligament reconstruction. Arthroscopy.2011 Aug;27(8):1055-9. Epub 2011 Jun 24.

44. Magnussen RA, Lawrence JT, West RL, Toth AP, Taylor DC, Garrett WE. Graftsize and patient age are predictors of early revision after anterior cruciate ligamentreconstructionwith hamstring autograft. Arthroscopy. 2012 Apr;28(4):526-31. Epub2012 Feb 01.

45. Guo L, Yang L, Duan XJ, He R, Chen GX, Wang FY, Zhang Y. Anterior cruciateligamentreconstruction withbone-patellar tendon-bone graft: comparison of autograft,fresh-frozen allograft, and g-irradiated allograft. Arthroscopy. 2012 Feb;28(2):211-7.

46. Rappe M, Horodyski M, Meister K, Indelicato PA. Nonirradiated versus irradiatedAchilles allograft: in vivo failure comparison. Am J Sports Med. 2007 Oct;35(10):1653-8. Epub 2007 May 21.

47. Krych AJ, Jackson JD, Hoskin TL, Dahm DL. A meta-analysis of patellar tendonautograft versus patellar tendon allograft in anterior cruciate ligament reconstruction.Arthroscopy. 2008 Mar;24(3):292-8. Epub 2007 Nov 05.

48. BorchersJR, Pedroza A, Kaeding C. Activity leveland graft type as risk factorsforanterior cruciate ligament graft failure: a case-control study. Am J Sports Med. 2009Dec;37(12):2362-7. Epub 2009 Aug 14.

49. Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, Dunn WR, MarxRG, McCarty EC, Parker RD, Wright RW, Spindler KP. Allograft Versus AutograftAnterior Cruciate Ligament Reconstruction: Predictors of Failure From a MOONProspective Longitudinal Cohort. Sports Health. 2011 Jan;3(1):73-81.

50. Singhal MC, Gardiner JR, Johnson DL. Failure of primary anterior cruciate liga-ment surgery using anterior tibialis allograft. Arthroscopy. 2007 May;23(5):469-75.

51. van Eck CF, Schkrohowsky JG, Working ZM, Irrgang JJ, Fu FH. Prospective analysisof failure rate and predictors of failure after anatomic anterior cruciate ligament recon-struction with allograft. Am J Sports Med. 2012 Apr;40(4):800-7. Epub 2012 Jan 11.

52. Leys T, Salmon L, Waller A, Linklater J, Pinczewski L. Clinical results and riskfactors for reinjury 15 years after anterior cruciate ligament reconstruction: a prospec-tive study of hamstring and patellar tendon grafts. Am J Sports Med. 2012 Mar;40(3):595-605. Epub 2011 Dec 19.

53. Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anteriorcruciate ligament reconstruction. Am J Sports Med. 1992 Sep-Oct;20(5):499-506.

54. Tashman S, Collon D, Anderson K, Kolowich P, Anderst W. Abnormal rotationalknee motion during running after anterior cruciate ligament reconstruction. Am JSports Med. 2004 Jun;32(4):975-83.

55. McConkeyMO, AmendolaA, Ramme AJ,Dunn WR,FlaniganDC, BrittonCL, WolfBR, Spindler KP, Carey JL, Cox CL, Kaeding CC, Wright RW, Matava MJ, Brophy RH,Smith MV, McCarty EC, Vida AF, Wolcott M, Marx RG, Parker RD, Andrish JF, JonesMH; MOON Knee Group. Arthroscopic agreement among surgeons on anterior cru-ciate ligament tunnel placement. Am J Sports Med. 2012 Dec;40(12):2737-46.Epub 2012 Oct 17.

56. Illingworth KD, Hensler D, Working ZM, Macalena JA, Tashman S, Fu FH. A simpleevaluation of anterior cruciate ligament femoral tunnel position: the inclination angle andfemoral tunnel angle. Am J Sports Med. 2011 Dec;39(12):2611-8. Epub 2011 Sep 09.

57. BediA, MusahlV, SteuberV, Kendoff D,Choi D,AllenAA, PearleAD, Altchek DW.Transtibial versus anteromedial portal reaming in anterior cruciate ligament recon-struction: an anatomic and biomechanical evaluation of surgical technique. Ar-throscopy. 2011 Mar;27(3):380-90. Epub 2010 Oct 29.

58. Forsythe B, Kopf S, Wong AK, Martins CA, Anderst W, Tashman S, Fu FH. Thelocation of femoral and tibial tunnels in anatomic double-bundle anterior cruciateligamentreconstruction analyzedby three-dimensionalcomputed tomographymodels.J Bone Joint Surg Am. 2010 Jun;92(6):1418-26.

59. LertwanichP, Martins CA, AsaiS, Ingham SJ, SmolinskiP, Fu FH. Anteriorcruciateligament tunnel position measurement reliability on 3-dimensional reconstructedcomputed tomography. Arthroscopy. 2011 Mar;27(3):391-8. Epub 2010 Dec 03.

60. Meuffels DE, Potters JW, Koning AH, Brown CH Jr, Verhaar JA, Reijman M.Visualization of postoperative anterior cruciate ligament reconstruction bone tunnels:reliability of standard radiographs, CT scans, and 3D virtual reality images. ActaOrthop. 2011 Dec;82(6):699-703. Epub 2011 Oct 17.

61. FrobellRB, Roos EM, RoosHP, Ranstam J, Lohmander LS. A randomized trial oftreatment for acute anterior cruciate ligament tears. N Engl J Med. 2010 Jul 22;363(4):331-42.

62. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Treat-ment for acute anterior cruciate ligament tear: five year outcome of randomised trial.BMJ. 2013;346:f232. Epub 2013 Jan 24.

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.

65. Hussein M,van EckCF, Cretnik A, Dinevski D,Fu FH.Individualizedanteriorcruciateligament surgery: a prospective study comparing anatomic single- and double-bundlereconstruction. Am J Sports Med. 2012 Aug;40(8):1781-8. Epub 2012 May 16.

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.

68. Papalia R, Franceschi F, Zampogna B, Tecame A, Maffulli N, Denaro V. Surg icalmanagement of partial tears of the anterior cruciate Knee Surg Sports TraumatolArthrosc. 2012 Dec 23. [Epub ahead of print].

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69. Georgoulis AD, Papadonikolakis A, Papageorgiou CD, Mitsou A, Stergiou N.Three-dimensional tibiofemoral kinematics of the anterior cruciate ligament-deficientand reconstructed knee during walking. Am J Sports Med. 2003 Jan-Feb;31(1):75-9.

70. Abebe ES,Utturkar GM,Taylor DC,Spritzer CE,Kim JP,Moorman CT 3rd, GarrettWE, DeFrate LE. The effects of femoral graft placement on in vivo knee kinematicsafter anterior cruciate ligament reconstruction. J Biomech. 2011 Mar 15;44(5):924-9. Epub 2011 Jan 11.

71. Tashman S, Araki D. Effects of anterior cruciate ligament reconstruction onin vivo, dynamic knee function. Clin Sports Med. 2013 Jan;32(1):47-59.

72. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anteriorcruciate ligament reconstruction surgery: a systematic review and meta-analysis ofthe state of play. Br J Sports Med. 2011 Jun;45(7):596-606. Epub 2011 Mar 11.

73. Brophy RH,Schmitz L, Wright RW,Dunn WR,Parker RD, Andrish JT, McCarty EC,Spindler KP. Return to play and future ACL injury risk after ACL reconstruction insoccerathletes from the Multicenter OrthopaedicOutcomes Network (MOON) group.Am J Sports Med. 2012 Nov;40(11):2517-22. Epub 2012 Sep 21.

74. Smith FW,Rosenlund EA,Aune AK,MacLean JA,Hillis SW.Subjective functionalassessments and the return to competitive sport after anterior cruciate ligamentreconstruction. Br J Sports Med. 2004 Jun;38(3):279-84.

75. Rahr-Wagner L, Thillemann TM, Pedersen AB, Lind MC. Increased risk of revi-sionafter anteromedialcompared withtranstibialdrillingof the femoraltunnel duringprimary anterior cruciate ligament reconstruction: results from the Danish KneeLigament Reconstruction Register. Arthroscopy. 2013 Jan;29(1):98-105.

76. Yagi M, Wong EK, Kanamori A, Debski RE, Fu FH, Woo SL. Biomechanicalanalysis of an anatomic anterior cruciate ligament reconstruction. Am J Sports Med.

2002 Sep-Oct;30(5):660-6.77. K ato Y, Maeyama A, Lertwanich P, Wang JH, Ingham SJ, Kramer S, Martins CQ,Smolinski P, Fu FH. Biomechanical comparison of different graft positions forsingle-bundle anterior cruciate ligament reconstruction. Knee Surg SportsTraumatolArthrosc. 2013 Apr;21(4):816-23. Epub 2012 Mar 15.

78. Bourke HE, Salmon LJ, Waller A, Patterson V, Pinczewski LA. Survival of theanterior cruciate ligament graft and the contralateral ACL at a minimum of 15 years.Am J Sports Med. 2012 Sep;40(9):1985-92. Epub 2012 Aug 06.

79. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Ipsilateral graft and con-tralateral ACL rupture at five yearsor more followingACL reconstruction: a systematicreview. J Bone Joint Surg Am. 2011 Jun 15;93(12):1159-65.

80. Shelbourne KD, Gray T, Haro M. Incidence of subsequent injury to either kneewithin 5 years after anterior cruciate ligament reconstruction with patellar tendonautograft. Am J Sports Med. 2009 Feb;37(2):246-51. Epub 2008 Dec 24.

81. Li RT, Lorenz S, Xu Y, Harner CD, Fu FH, Irrgang JJ. Predictors of radiographickneeosteoarthritis after anterior cruciate ligament reconstruction. Am J SportsMed.2011 Dec;39(12):2595-603. Epub 2011 Oct 21.

82. Roe J, Pinczewski LA, Russell VJ, Salmon LJ, Kawamata T, Chew M. A 7-yearfollow-up of patellar tendon and hamstring tendon grafts for arthroscopic anteriorcruciate ligament reconstruction: differences and similarities. Am J Sports Med.2005 Sep;33(9):1337-45. Epub 2005 Jul 07.

83. Oiestad BE, Holm I, Aune AK, Gunderson R, Myklebust G, Engebretsen L,Fosdahl MA, Risberg MA. Knee function and prevalence of knee osteoarthritis afteranterior cruciate ligament reconstruction: a prospective study with 10 to 15 years offollow-up. Am J Sports Med. 2010 Nov;38(11):2201-10. Epub 2010 Aug 16.

84. iestad BE, Holm I, Engebretsen L, Aune AK, Gunderson R, Risberg MA. Theprevalence of patellofemoral osteoarthritis 12 years after anterior cruciate ligamentreconstruction. Knee Surg Sports Traumatol Arthrosc. 2013 Apr;21(4):942-9. Epub2012 Aug 17.

85. SalmonLJ, Russell VJ,Refshauge K, Kader D,ConnollyC, LinklaterJ, Pinczewski LA.Long-term outcome of endoscopic anterior cruciate ligament reconstruction withpatellar tendon autograft: minimum 13-year review. Am J Sports Med. 2006May;34(5):721-32. Epub 2006 Jan 06.

86. Shelbourne KD, Urch SE, Gray T, Freeman H. Loss of normal knee motion afteranterior cruciate ligament reconstruction is associated with radiographic arthriticchanges after surgery. Am J Sports Med. 2012 Jan;40(1):108-13. Epub 2011

Oct 11.87. Shelbourne KD, Gray T. Minimum 10-year results after anterior cruciate ligamentreconstruction: how the loss of normal knee motion compounds other factors relatedto the development of osteoarthritis after surgery. Am J Sports Med. 2009 Mar;37(3):471-80. Epub 2008 Dec 04.

88. Lebel B, Hulet C, Galaud B, Burdin G, Locker B, Vielpeau C. Arthroscopic recon-structionof theanteriorcruciateligament using bone-patellartendon-bone autograft:aminimum 10-year follow-up. Am J Sports Med. 2008 Jul;36(7):1275-82. Epub 2008Mar 19.

89. Wright JG, Einhorn TA, Heckman JD. Grades of recommendation. J Bone JointSurg Am. 2005 Sep 01;87(9):1909-10.

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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: [email protected] 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:[email protected]:[email protected]:[email protected]


12/19

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-


po



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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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