Longitudinal changes in adiposity following anterior cruciate ligament reconstruction and associations with knee symptoms and function.

Objective: To evaluate adiposity after anterior cruciate ligament reconstruction (ACLR): i) cross-sectionally (1-year post-ACLR) compared to uninjured controls; ii) longitudinally up to 5 years post-ACLR; and iii) associations with patient-reported symptoms and physical performance. Methods: In 107 individuals post-ACLR and 19 controls, we assessed global (BMI), peripheral (subcutaneous adipose tissue thickness on the posteromedial side of knee MRI), and central (waist circumference in ACLR group) adiposity. Patient-reported symptoms (Knee injury and Osteoarthritis Outcome Score) and physical performance (hop for distance) were evaluated at 1 and 5 years post-ACLR. Linear regression models evaluated adiposity between groups. Paired t-tests evaluated changes in adiposity from 1- to 5 years post-ACLR. Linear regression models analyzed adiposity's associations with patient-reported symptoms and physical performance at 1-year post-ACLR, changes in symptoms and performance over 4 years post-ACLR, and longitudinal changes in adiposity and symptoms and performance, controlling for age, sex, and activity level. Results: Individuals 1-year post-ACLR were associated with higher average global (3 â€‹kg/m2) and peripheral adiposity (2.3 â€‹mm). From 1- to 5 years post-ACLR, higher average global (0.58 â€‹kg/m2) and central (5 â€‹cm) adiposity, and lower average peripheral adiposity (1.3 â€‹mm) were observed. In general, adiposity at one-year post-ACLR was negatively associated with patient-reported symptoms and physical performance, and changes from 1 to 5 years post-ACLR. Increases in adiposity were negatively associated with changes in patient-reported symptoms and physical performance over four years post-ACLR. Conclusion: Greater global and central adiposity is a feature of young adults following ACLR and influences current and future patient-reported symptoms and physical performance.

Adiposity and cartilage lesions following ACL reconstruction.

OBJECTIVE: To determine if global, central, or peripheral adiposity is associated with prevalent and worsening cartilage lesions following anterior cruciate ligament reconstruction (ACLR). METHODS: In 107 individuals one-year post-ACLR, adiposity was assessed globally (body mass index), centrally (waist circumference), and peripherally (knee subcutaneous adipose tissue thickness) from magnetic resonance imaging (MRI). Tibiofemoral and patellofemoral cartilage lesions were assessed from knee MRIs at 1- and 5-years post-ACLR. Poisson regression evaluated the relation of adiposity with prevalent and worsening tibiofemoral and patellofemoral cartilage lesions adjusting for age, sex, and activity level. RESULTS: The prevalence ratios of adiposity with tibiofemoral (presence in 49%) and patellofemoral (44%) cartilage lesions ranged from 0.99 to 1.03. Adiposity was more strongly associated with longitudinal changes in tibiofemoral (worsening in 21%) and patellofemoral (44%) cartilage lesions. One-unit increase in global (kg/m2), central (cm), and peripheral (mm) adiposity was associated with a higher risk of worsening tibiofemoral cartilage lesions by 17% (risk ratios [95% confidence interval (CI)]: 1.17 [1.09 to 1.23]), 5% (1.05 [1.02 to 1.08]), and 9% (1.09 [1.03 to 1.16]), and patellofemoral cartilage lesions by 5% (1.05 [1.00 to 1.12]), 2% (1.02 [1.00 to 1.04]) and 2% (1.02 [1.00 to 1.04]), respectively. CONCLUSION: Greater adiposity was a risk factor for worsening cartilage lesions up to 5 years post-ACLR. Clinical interventions aimed at mitigating excess adiposity may be beneficial in preventive approaches for early post-traumatic osteoarthritis.

Recruitment and baseline characteristics of young adults at risk of early-onset knee osteoarthritis after ACL reconstruction in the SUPER-Knee trial.

Objectives: The study aims to (1) report the process of recruiting young adults into a secondary knee osteoarthritis prevention randomised controlled trial (RCT) after anterior cruciate ligament reconstruction (ACLR); (2) determine the number of individuals needed to be screened to include one participant (NNS) and (3) report baseline characteristics of randomised participants. Methods: The SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER)-Knee RCT compares SUPER and minimal intervention for young adults (aged 18-40 years) with ongoing symptoms (ie, mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score subscales (KOOS4)) 9-36 months post-ACLR. The NNS was calculated as the number of prospective participants screened to enrol one person. At baseline, participants provided medical history, completed questionnaires (demographic, injury/surgery, rehabilitation characteristics) and underwent physical examination. Results: 1044 individuals were screened to identify 567 eligible people, from which 184 participants (63% male) enrolled. The sample of enrolled participants was multicultural (29% born outside Australia; 2% Indigenous Australians). The NNS was 5.7. For randomised participants, mean±SD age was 30±6 years. The mean body mass index was 27.3±5.2 kg/m2, with overweight (43%) and obesity (21%) common. Participants were, on average, 2.3 years post-ACLR. Over half completed <8 months of postoperative rehabilitation, with 56% having concurrent injury/surgery to meniscus and/or cartilage. The most affected KOOS (0=worst, 100=best) subscale was quality of life (mean 43.7±19.1). Conclusion: Young adults post-ACLR were willing to participate in a secondary osteoarthritis prevention trial. Sample size calculations should be multiplied by at least 5.7 to provide an estimate of the NNS. The SUPER-Knee cohort is ideally positioned to monitor and intervene in the early development and trajectory of osteoarthritis. Trial registration number: ACTRN12620001164987.

Injury prevention for women and girls playing Australian Football: programme cocreation, dissemination and early adopter coach feedback.

Background: Adherence to injury prevention programmes may improve with greater end-user involvement and application of implementation frameworks during development. We describe the cocreation, initial dissemination and feedback from programme early adopters (coaches), to develop the first evidence-informed injury prevention programme for women playing community Australian Football (Prep-to-Play). Methods: We used a pragmatic seven-step process for developing sports injury prevention programmes to (1) gain organisational support, (2) compile research evidence, (3) consult experts, (4) engage end-users, (5) test programme acceptability, (6) evaluate against theory and (7) gain early adopter feedback. All Australian Football-registered coaches of women's/girls' teams were sent a postseason survey to determine initial awareness, adoption and implementation (steps 5 and 6). Purposively selected coaches were invited to interviews/focus groups (step 7) to identify competency, organisational and leadership implementation drivers with a deductive thematic analysis applied. Results: Prep-to-Play was cocreated using previous efficacious programmes and expert input (steps 1-4), and disseminated via the national sporting organisation in preseason 2019 to all registered coaches (step 5). 343 coaches (90 women) completed the postseason survey and 22 coaches (5 women) participated in an interview (n=9) or focus group (n=13) (steps 6 and 7). 268 coaches (78%) were aware of Prep-to-Play. Of those aware, 218 (81%) had used (at least one element) Prep-to-Play, and 143 (53%) used it at least twice per week. Competency drivers included local expert-delivered face-to-face workshops complimented by online content and ongoing support. Organisational drivers included coach education integrated into existing league/club. Leadership drivers included compulsory injury prevention education integrated into coach reaccreditation processes or incentivisation via recognition (eg, professional development points). Conclusions: Cocreation and organisational support resulted in high programme awareness and adoption. However, high fidelity implementation and maintenance may need to be facilitated by competency, organisational and leadership drivers. Responsibility should be shared among all stakeholders.

If we build it together, will they use it? A mixed-methods study evaluating the implementation of Prep-to-Play PRO: an injury prevention programme for women's elite Australian Football.

OBJECTIVES: We evaluated the implementation of Prep-to-Play PRO, an injury prevention programme for women's elite Australian Football League (AFLW). METHODS: The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of Prep-to-Play PRO were assessed based on the proportion of AFLW players and/or staff who: were aware of the programme (R), believed it may reduce anterior cruciate ligament injury (E), attempted to implement any/all programme components (A), implemented all intended components as practically as possible (I) and intended future programme implementation (M). Quantitative and qualitative data were triangulated to assess 58 RE-AIM items (evidence of yes/no/unsure/no evidence) and the 5 RE-AIM dimensions (fully achieved=evidence of yes on >50% dimension items, partially achieved=50% of items evidence of yes and 50% unsure or 50% mix of unsure and unanswered, or not met=evidence of yes on <50% dimension items). RESULTS: Multiple sources including AFLW training observations (n=7 total), post-implementation surveys (141 players, 25 staff), semistructured interviews (19 players, 13 staff) and internal programme records (9 staff) contributed to the RE-AIM assessment. After the 2019 season, 8 of 10 (80%) AFLW clubs fully met all five RE-AIM dimensions. All 10 clubs participating in the AFLW fully achieved the reach (R) dimension. One club partially achieved the implementation (I) dimension, and one club partially achieved the effectiveness (E) and adoption (A) dimensions. CONCLUSION: The Prep-to-Play PRO injury prevention programme for the AFLW achieved high implementation, possibly due to the programme's deliberately flexible approach coupled with our pragmatic definition of implementation. Engaging key stakeholders at multiple ecological levels (organisation, coaches, athletes) throughout programme development and implementation likely enhanced programme implementation.

Hip rotation muscle strength is implicated in the progression of early post-traumatic osteoarthritis: A longitudinal evaluation up to 5 years following ACL reconstruction.

INTRODUCTION: Following ACL reconstruction (ACLR), deficits in hip muscle strength and relationships to future outcomes are unknown. METHODS: 111 participants one year after ACLR, completed hip external rotation (ER) and internal rotation (IR) strength assessment. At 1 (n = 111) and 5 (n = 74) years post-ACLR, participants completed a battery of functional, symptomatic (Knee Osteoarthritis Outcome Score (KOOS)) and structural assessments (radiography, magnetic resonance imaging (MRI)). Cartilage health of the patellofemoral and tibiofemoral compartments was assessed with the semiquantitative MRI Osteoarthritis Knee Score. Hip rotation strength was compared between-limbs, and relationships between hip strength at 1 year and functional, symptomatic and cartilage outcomes at 1 and 5 years were investigated with regression models. RESULTS: The index (ACLR) limb had weaker hip ER (but not IR) strength compared to the contralateral side (standardised mean difference ER = -0.33 (95%CI -0.60, -0.07; IR = -0.11 (95%CI -0.37, 0.15). Greater hip ER and IR strength was associated with superior function at 1 and 5 years, and better KOOS-Patellofemoral symptoms at 5 years. Greater hip ER strength was associated with lower odds of worsening tibiofemoral cartilage lesions at 5 years (odds ratio 0.01, 95%CI 0.00, 0.41). CONCLUSION: Hip rotation strength may play a role in worsening function, symptoms and cartilage health after ACLR.

Knee- and Overall Health-Related Quality of Life Following Anterior Cruciate Ligament Injury: A Cross-sectional Analysis of Australian and Canadian Cohorts.

OBJECTIVE: To describe the knee- and overall health-related quality of life (QOL) 3 to 12 years after anterior cruciate ligament (ACL) tear, and to assess the association of clinical and structural features with QOL after ACL tear. DESIGN: Cross-sectional analysis of combined data from Australian (n = 76, 5.4 years postinjury) and Canadian (n = 50, 6.6 years postinjury) prospective cohort studies. METHODS: We conducted a secondary analysis of patient-reported outcomes and index knee magnetic resonance imaging (MRI) acquired in 126 patients (median 5.5 [range: 4-12] years postinjury), all treated with ACL reconstruction. Outcomes included knee (ACL Quality of Life questionnaire [ACL-QOL]) and overall health-related QOL (EQ-5D-3L). Explanatory variables were self-reported knee pain (Knee Injury and Osteoarthritis Outcome Score [KOOS-Pain subscale]) and function (KOOS-Sport subscale), and any knee cartilage lesion (MRI Osteoarthritis Knee Score). Generalized linear models were adjusted for clustering between sites. Covariates were age, sex, time since injury, injury type, subsequent knee injuries, and body mass index. RESULTS: The median [range] ACL-QOL score was 82 [24-100] and EQ-5D-3L was 1.0 [-0.2 to 1.0]. For every 10-point higher KOOS-Sport score, the ACL-QOL score increased by 3.7 points (95% confidence interval [CI]: 1.7, 5.7), whereas there was no evidence of an association with the EQ-5D-3L (0.00 points, 95% CI: -0.02, 0.02). There were no significant association between KOOS-Pain and ACL-QOL (4.9 points, 95% CI: -0.1, 9.9) or EQ-5D-3L (0.05 points, 95% CI: -0.01, 0.11), respectively. Cartilage lesions were not associated with ACL-QOL (-1.2, 95% CI: -5.1, 2.7) or EQ-5D-3L (0.01, 95% CI: -0.01, 0.04). CONCLUSION: Self-reported function was more relevant for knee-related QOL than knee pain or cartilage lesions after ACL tear. Self-reported function, pain, and knee structural changes were not associated with overall health-related QOL. J Orthop Sports Phys Ther 2023;53(7):1-12. Epub: 8 June 2023. doi:10.2519/jospt.2023.11838.

The Effects of Different Management Strategies or Rehabilitation Approaches on Knee Joint Structural and Molecular Biomarkers Following Traumatic Knee Injury: A Systematic Review of Randomized Controlled Trials for the OPTIKNEE Consensus.

OBJECTIVE: To summarize the effectiveness of management strategies and rehabilitation approaches for knee joint structural and molecular biomarker outcomes following anterior cruciate ligament (ACL) and/or meniscal tear. DESIGN: Intervention systematic review. LITERATURE SEARCH: We searched the MEDLINE, Embase, CINAHL, CENTRAL, and SPORTDiscus databases from their inception up to November 3, 2021. STUDY SELECTION CRITERIA: We included randomized controlled trials (RCTs) investigating the effectiveness of management strategies or rehabilitation approaches for structural/molecular biomarkers of knee joint health following ACL and/or meniscal tear. DATA SYNTHESIS: We included 5 RCTs (9 papers) with primary ACL tear (n = 365). Two RCTs compared initial management strategies (rehabilitation plus early vs optional delayed ACL surgery), reporting on structural biomarkers (radiographic osteoarthritis, cartilage thickness, meniscal damage) in 5 papers and molecular biomarkers (inflammation, cartilage turnover) in 1 paper. Three RCTs compared different post-ACL reconstruction (ACLR) rehabilitation approaches (high vs low intensity plyometric exercises, accelerated vs nonaccelerated rehabilitation, continuous passive vs active motion), reporting on structural biomarkers (joint space narrowing) in 1 paper and molecular biomarkers (inflammation, cartilage turnover) in 2 papers. RESULTS: There were no differences in structural or molecular biomarkers between post-ACLR rehabilitation approaches. One RCT comparing initial management strategies demonstrated that rehabilitation plus early ACLR was associated with greater patellofemoral cartilage thinning, elevated inflammatory cytokine response, and reduced incidence of medial meniscal damage over 5 years compared to rehabilitation with no/delayed ACLR. CONCLUSION: Very low-certainty evidence suggests that different initial management strategies (rehabilitation plus early vs optional delayed ACL surgery) but not postoperative rehabilitation approaches may influence the incidence of meniscal damage, patellofemoral cartilage loss and cytokine concentrations over 5 years post-ACL tear. J Orthop Sports Phys Ther 2023;53(4):1-22. Epub: 20 February 2023. doi:10.2519/jospt.2023.11576.

Patellofemoral joint loading and early osteoarthritis after ACL reconstruction.

Patellofemoral joint (PFJ) osteoarthritis is common following anterior cruciate ligament reconstruction (ACLR) and may be linked with altered joint loading. However, little is known about the cross-sectional and longitudinal relationship between PFJ loading and osteoarthritis post-ACLR. This study tested if altered PFJ loading is associated with prevalent and worsening early PFJ osteoarthritis post-ACLR. Forty-six participants (mean ± 1 SD age 26 ± 5 years) approximately 1-year post-ACLR underwent magnetic resonance imaging (MRI) and biomechanical assessment of their reconstructed knee. Trunk and lower-limb kinematics plus ground reaction forces were recorded during the landing phase of a standardized forward hop. These data were input into a musculoskeletal model to calculate the PFJ contact force. Follow-up MRI was completed on 32 participants at 5-years post-ACLR. Generalized linear models (Poisson regression) assessed the relationship between PFJ loading and prevalent early PFJ osteoarthritis (i.e., presence of a PFJ cartilage lesion at 1-year post-ACLR) and worsening PFJ osteoarthritis (i.e., incident/progressive PFJ cartilage lesion between 1- and 5-years post-ACLR). A lower peak PFJ contact force was associated with prevalent early PFJ osteoarthritis at 1-year post-ACLR (n = 14 [30.4%]; prevalence ratio: 1.37; 95% confidence interval [CI]: 1.02-1.85) and a higher risk of worsening PFJ osteoarthritis between 1- and 5-years post-ACLR (n = 9 [28.1%]; risk ratio: 1.55, 95% CI: 1.13-2.11). Young adults post-ACLR who exhibited lower PFJ loading during hopping were more likely to have early PFJ osteoarthritis at 1-year and worsening PFJ osteoarthritis between 1- and 5-years. Clinical interventions aimed at mitigating osteoarthritis progression may be beneficial for those with signs of lower PFJ loading post-ACLR.

Trajectory of knee health in runners with and without heightened osteoarthritis risk: the TRAIL prospective cohort study protocol.

INTRODUCTION: Running is one of the most popular recreational activities worldwide, due to its low cost and accessibility. However, little is known about the impact of running on knee joint health in runners with and without a history of knee surgery. The primary aim of this longitudinal cohort study is to compare knee joint structural features on MRI and knee symptoms at baseline and 4-year follow-up in runners with and without a history of knee surgery. Secondary aims are to explore the relationships between training load exposures (volume and/or intensity) and changes in knee joint structure and symptoms over 4 years; explore the relationship between baseline running biomechanics, and changes in knee joint structure and symptoms over 4 years. In addition, we will explore whether additional variables confound, modify or mediate these associations, including sex, baseline lower-limb functional performance, knee muscle strength, psychological and sociodemographic factors. METHODS AND ANALYSIS: A convenience sample of at least 200 runners (sex/gender balanced) with (n=100) and without (n=100) a history of knee surgery will be recruited. Primary outcomes will be knee joint health (MRI) and knee symptoms (baseline; 4 years). Exposure variables for secondary outcomes include training load exposure, obtained daily throughout the study from wearable devices and three-dimensional running biomechanics (baseline). Additional variables include lower limb functional performance, knee extensor and flexor muscle strength, biomarkers, psychological and sociodemographic factors (baseline). Knowledge and beliefs about osteoarthritis will be obtained through predefined questions and semi-structured interviews with a subset of participants. Multivariable logistic and linear regression models, adjusting for potential confounding factors, will explore changes in knee joint structural features and symptoms, and the influence of potential modifiers and mediators. ETHICS AND DISSEMINATION: Approved by the La Trobe University Ethics Committee (HEC-19524). Findings will be disseminated to stakeholders, peer-review journals and conferences.

SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) versus minimal intervention for young adults at risk of knee osteoarthritis after ACL reconstruction: SUPER-Knee randomised controlled trial protocol.

INTRODUCTION: Anterior cruciate ligament injury and reconstruction (ACLR) is often associated with pain, functional loss, poor quality of life and accelerated knee osteoarthritis development. The effectiveness of interventions to enhance outcomes for those at high risk of early-onset osteoarthritis is unknown. This study will investigate if SUpervised exercise-therapy and Patient Education Rehabilitation (SUPER) is superior to a minimal intervention control for improving pain, function and quality of life in young adults with ongoing symptoms following ACLR. METHODS AND ANALYSIS: The SUPER-Knee Study is a parallel-group, assessor-blinded, randomised controlled trial. Following baseline assessment, 184 participants aged 18-40 years and 9-36 months post-ACLR with ongoing symptoms will be randomly allocated to one of two treatment groups (1:1 ratio). Ongoing symptoms will be defined as a mean score of <80/100 from four Knee injury and Osteoarthritis Outcome Score (KOOS4) subscales covering pain, symptoms, function in sports and recreational activities and knee-related quality of life. Participants randomised to SUPER will receive a 4-month individualised, physiotherapist-supervised strengthening and neuromuscular programme with education. Participants randomised to minimal intervention (ie, control group) will receive a printed best-practice guide for completing neuromuscular and strengthening exercises following ACLR. The primary outcome will be change in the KOOS4 from baseline to 4 months with a secondary endpoint at 12 months. Secondary outcomes include change in individual KOOS subscale scores, patient-perceived improvement, health-related quality of life, kinesiophobia, physical activity, thigh muscle strength, knee function and knee cartilage morphology (ie, lesions, thickness) and composition (T2 mapping) on MRI. Blinded intention-to-treat analyses will be performed. Findings will also inform cost-effectiveness analyses. ETHICS AND DISSEMINATION: This study is approved by the La Trobe University and Alfred Hospital Ethics Committees. Results will be presented in peer-reviewed journals and at international conferences. TRIAL REGISTRATION NUMBER: ACTRN12620001164987.

Creating Prep to Play PRO for women playing elite Australian football: A how-to guide for developing injury-prevention programs.

BACKGROUND: Developing context-specific, evidence-informed, and implementable injury-prevention programs is challenging. Women playing in the elite Australian Football League for Women are at high risk of serious knee injuries, and no specific injury-prevention program exists. The objective of the study was to describe the collaborative process used to create a context-specific injury-prevention program. METHODS: A previously used intervention-development process was modified to incorporate a partnership with the sport's governing organization and focus on engaging program implementers. The Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Sports Setting Matrix guided program development and implementation strategies. RESULTS: The 7-step process, aligned with the RE-AIM Sports Setting Matrix, was applied to develop the injury-prevention program and was titled Prep to Play PRO. The steps were: (Step 1) gaining organizational support and establishing a project partnership; (Step 2) using research evidence and clinical experience; (Step 3) consulting content and context experts; (Step 4) engaging the organization, experts, program implementers, and end-users to concreate the intervention and develop implementation strategies; (Step 5) testing the intervention acceptability and feasibility; (Step 6) evaluating the intervention and implementation strategies against theory; and (Step 7) obtaining feedback from early implementers and end-users. CONCLUSION: Engaging critical stakeholders at multiple ecological levels (organization, team, and athlete) throughout program development and implementation planning support real-world use. The processes and activities described can guide future sports injury-prevention program development and implementation.

Muscle strength and osteoarthritis of the knee: a systematic review and meta-analysis of longitudinal studies.

OBJECTIVE: To evaluate the sex-specific association between low knee extensor and flexor muscle strength and the risk of knee structural worsening. MATERIALS AND METHODS: Systematic searches in five databases identified longitudinal studies (≥ 1 year follow-up) reporting an association between knee extensor or flexor strength and structural decline in individuals with, or at risk of, knee osteoarthritis. Results were pooled for tibiofemoral and patellofemoral osteoarthritis worsening (and stratified by sex/gender where possible) using a random-effects meta-analysis estimating the risk ratio and 95% confidence interval or a best-evidence synthesis. Risk of bias and overall certainty of evidence were assessed. RESULTS: Fourteen studies were included with participants (mean age 27-72 years) with osteoarthritis (n = 8), at risk of osteoarthritis (n = 3), or a combination with, or at risk of, osteoarthritis (n = 3). Low knee extensor strength was associated with an increased risk of worsening tibiofemoral (12 studies: RR 1.18, 95% CI 1.04 to 1.35) and patellofemoral osteoarthritis (4 studies: RR 1.62, 95% CI 1.01 to 2.61). Significant associations between low knee extensor strength and worsening tibiofemoral osteoarthritis were observed for women (4 studies: RR 1.25, 95% CI 1.04 to 1.51) but not men (4 studies: RR 1.10, 95% CI 0.87 to 1.39). Low knee flexor strength increased the risk of worsening tibiofemoral osteoarthritis (5 studies: RR 1.16, 95% CI 1.07 to 1.26). Ten studies were high risk of bias, and all estimates were graded as very low certainty of evidence. CONCLUSION: Low knee extensor and flexor strength increased the risk of worsening tibiofemoral osteoarthritis. Low knee extensor strength increased the risk of worsening patellofemoral osteoarthritis. The relationship between low knee extensor strength and worsening tibiofemoral osteoarthritis may be modified by sex/gender.

Evaluation of an injury prevention programme (Prep-to-Play) in women and girls playing Australian Football: design of a pragmatic, type III, hybrid implementation-effectiveness, stepped-wedge, cluster randomised controlled trial.

INTRODUCTION: Due to the increase in participation and risk of anterior cruciate ligament (ACL) injuries and concussion in women's Australian Football, an injury prevention programme (Prep-to-Play) was codesigned with consumers (eg, coaches, players) and stakeholders (eg, the Australian Football League). The impact of supported and unsupported interventions on the use of Prep-to-Play (primary aim) and injury rates (secondary aim) will be evaluated in women and girls playing community Australian Football. METHODS AND ANALYSIS: This stepped-wedge, cluster randomised controlled trial will include ≥140 teams from U16, U18 or senior women's competitions. All 10 geographically separated clusters (each containing ≥14 teams) will start in the control (unsupported) phase and be randomised to one of five dates (or 'wedges') during the 2021 or 2022 season to sequentially transition to the intervention (supported Prep-to-Play), until all teams receive the intervention. Prep-to-Play includes four elements: a neuromuscular training warm-up, contact-focussed football skills (eg, tackling), strength exercises and education (eg, technique cues). When transitioning to supported interventions, study physiotherapists will deliver a workshop to coaches and player leaders on how to use Prep-to-Play, attend team training at least two times and provide ongoing support. In the unsupported phase, team will continue usual routines and may freely access available Prep-to-Play resources online (eg, posters and videos about the four elements), but without additional face-to-face support. Outcomes will be evaluated throughout the 2021 and 2022 seasons (~14 weeks per season). PRIMARY OUTCOME: use of Prep-to-Play will be reported via a team designate (weekly) and an independent observer (five visits over the two seasons) and defined as the team completing 75% of the programme, two-thirds (67%) of the time. SECONDARY OUTCOMES: injuries will be reported by the team sports trainer and/or players. Injury definition: any injury occurring during a football match or training that results in: (1) being unable to return to the field of play for that match or (2) missing ≥ one match. Outcomes in the supported and unsupported phases will be compared using a generalised linear mixed model adjusting for clustering and time. Due to the type III hybrid implementation-effectiveness design, the study is powered to detect a improvement in use of Prep-to-Play and a reduction in ACL injuries. ETHICS AND DISSEMINATION: La Trobe University Ethics Committee (HREC 20488) approved. Coaches provided informed consent to receive the supported intervention and players provided consent to be contacted if they sustained a head or knee injury. Results will be disseminated through partner organisations, peer-reviewed publications and scientific conferences. TRIAL REGISTRATION NUMBER: NCT04856241.

Rehabilitation after anterior cruciate ligament and meniscal injuries: a best-evidence synthesis of systematic reviews for the OPTIKNEE consensus.

OBJECTIVE: Synthesise evidence for effectiveness of rehabilitation interventions following ACL and/or meniscal tear on symptomatic, functional, clinical, psychosocial, quality of life and reinjury outcomes. DESIGN: Overview of systematic reviews with Grading of Recommendations Assessment, Development and Evaluation certainty of evidence. DATA SOURCES: MEDLINE, EMBASE, CINAHL, SPORTDiscus and Cochrane Library. ELIGIBILITY CRITERIA: Systematic reviews of randomised controlled trials investigating rehabilitation interventions following ACL and/or meniscal tears in young adults. RESULTS: We included 22 systematic reviews (142 trials of mostly men) evaluating ACL-injured individuals and none evaluating isolated meniscal injuries. We synthesised data from 16 reviews evaluating 12 different interventions. Moderate-certainty evidence was observed for: (1) neuromuscular electrical stimulation to improve quadriceps strength; (2) open versus closed kinetic chain exercises to be similarly effective for quadriceps strength and self-reported function; (3) structured home-based versus structured in-person rehabilitation to be similarly effective for quadriceps and hamstring strength and self-reported function; and (4) postoperative knee bracing being ineffective for physical function and laxity. There was low-certainty evidence that: (1) preoperative exercise therapy improves self-reported and physical function postoperatively; (2) cryotherapy reduces pain and analgesic use; (3) psychological interventions improve anxiety/fear; and (4) whole body vibration improves quadriceps strength. There was very low-certainty evidence that: (1) protein-based supplements improve quadriceps size; (2) blood flow restriction training improves quadriceps size; (3) neuromuscular control exercises improve quadriceps and hamstring strength and self-reported function; and (4) continuous passive motion has no effect on range of motion. CONCLUSION: The general level of evidence for rehabilitation after ACL or meniscal tear was low. Moderate-certainty evidence indicates that several rehabilitation types can improve quadriceps strength, while brace use has no effect on knee function/laxity.

May the force be with you: understanding how patellofemoral joint reaction force compares across different activities and physical interventions-a systematic review and meta-analysis.

OBJECTIVE: To systematically review and synthesise patellofemoral joint reaction force (PFJRF) in healthy individuals and those with patellofemoral pain and osteoarthritis (OA), during everyday activities, therapeutic exercises and with physical interventions (eg, foot orthotics, footwear, taping, bracing). DESIGN: A systematic review with meta-analysis. DATA SOURCES: Medline, Embase, Scopus, CINAHL, SportDiscus and Cochrane Library databases were searched. ELIGIBILITY CRITERIA: Observational and interventional studies reporting PFJRF during everyday activities, therapeutic exercises, and physical interventions. RESULTS: In healthy individuals, the weighted average of mean (±SD) peak PFJRF for everyday activities were: walking 0.9±0.4 body weight (BW), stair ascent 3.2±0.7 BW, stair descent 2.8±0.5 BW and running 5.2±1.2 BW. In those with patellofemoral pain, peak PFJRF were: walking 0.8±0.2 BW, stair ascent 2.5±0.5 BW, stair descent 2.6±0.5 BW, running 4.1±0.9 BW. Only single studies reported peak PFJRF during everyday activities in individuals with patellofemoral OA/articular cartilage defects (walking 1.3±0.5 BW, stair ascent 1.6±0.4 BW, stair descent 1.0±0.5 BW). The PFJRF was reported for many different exercises and physical interventions; however, considerable variability precluded any pooled estimates. SUMMARY: Everyday activities and exercises involving larger knee flexion (eg, squatting) expose the patellofemoral joint to higher PFJRF than those involving smaller knee flexion (eg, walking). There were no discernable differences in peak PFJRF during everyday activities between healthy individuals and those with patellofemoral pain/OA. The information on PFJRF may be used to select appropriate variations of exercises and physical interventions.

Infrapatellar fat pad volume and Hoffa-synovitis after ACL reconstruction: Association with early osteoarthritis features and pain over 5 years.

Infrapatellar fat pad (IPFP) morphology and Hoffa-synovitis may be relevant to the development and progression of post-traumatic osteoarthritis (OA). We aimed to compare IPFP volume and Hoffa-synovitis in participants with anterior cruciate ligament reconstruction (ACLR) and uninjured controls, and to determine their association with prevalent and worsening early knee OA features and pain in participants post-ACLR. We assessed IPFP volume and Hoffa-synovitis from magnetic resonance imaging (MRI) in 111 participants 1-year post-ACLR and 20 uninjured controls. Patellofemoral and tibiofemoral cartilage and bone marrow lesions (BMLs) were assessed from MRIs at 1 and 5 years post-ACLR, and worsening defined as any longitudinal increase in lesion size/severity. IPFP volume and Hoffa-synovitis prevalence were compared between groups with analysis of covariance and χ 2 tests, respectively. Generalized linear models assessed the relation of IPFP volume and Hoffa-synovitis to prevalent and worsening features of OA and knee pain (Knee injury and Osteoarthritis Outcome Score-Pain Subscale, Anterior Knee Pain Scale). No significant between-group differences were observed in IPFP volume (ACLR 34.39 ± 7.29cm3 , Control 34.27 ± 7.56cm3 ) and Hoffa-synovitis (ACLR 61%, Control 80%). Greater IPFP volume at 1-year post-ACLR was associated with greater odds of patellofemoral BMLs at 1-year (odds ratio [OR] [95% confidence intervals]: 1.104 [1.016, 1.200]) and worsening tibiofemoral cartilage lesions at 5-year post-ACLR (OR: 1.234 [1.026, 1.483]). Hoffa-synovitis at 1-year post-ACLR was associated with greater odds of worsening patellofemoral BMLs at 5-year post-ACLR (OR: 7.465 [1.291, 43.169]). In conclusion, IPFP volume and Hoffa-synovitis prevalence are similar between individuals 1-year post-ACLR and controls. Greater IPFP volume and Hoffa-synovitis appear to be associated with the presence and worsening of some early OA features in those post-ACLR, but not pain.

Exercise-therapy and education for individuals one year after anterior cruciate ligament reconstruction: a pilot randomised controlled trial.

BACKGROUND: Guided rehabilitation beyond 6-months is rare following anterior cruciate ligament reconstruction (ACLR), despite high prevalence of unacceptable symptoms and quality of life (QoL). Our primary aim was to determine the feasibility of a randomised controlled trial (RCT) evaluating a physiotherapist-guided intervention for individuals 1-year post-ACLR with persistent symptoms. Our secondary aim was to determine if a worthwhile treatment effect could be observed for the lower-limb focussed intervention (compared to the trunk-focussed intervention), for improvement in knee-related QoL, symptoms, and function. DESIGN: Participant- and assessor-blinded, pilot feasibility RCT. METHODS: Participant eligibility criteria: i) 12-15 months post-ACLR; ii) < 87.5/100 on the Knee injury and Osteoarthritis Outcome Score (KOOS) QoL subscale; and either a one-leg rise test < 22 repetitions, single-hop < 90% limb symmetry; or Anterior Knee Pain Scale < 87/100. Participants were randomised to lower-limb or trunk-focussed focussed exercise and education. Both interventions involved 8 face-to-face physiotherapy sessions over 16-weeks. Feasibility was assessed by eligibility rate (> 1 in 3 screened), recruitment rate (> 4 participants/month), retention (< 20% drop-out), physiotherapy attendance and unsupervised exercise adherence (> 80%). Between-group differences for knee-related QoL (KOOS-QoL, ACL-QoL), symptoms (KOOS-Pain, KOOS-Symptoms), and function (KOOS-Sport, functional performance tests) were used to verify that the worthwhile effect (greater than the minimal detectable change for each measure) was contained within the 95% confidence interval. RESULTS: 47% of those screened were eligible, and 27 participants (3 participants/month; 48% men, 34±12 years) were randomised. Two did not commence treatment, and two were lost to follow-up (16% drop-out). Physiotherapy attendance was > 80% for both groups but reported adherence to unsupervised exercise was low (< 55%). Both interventions had potentially worthwhile effects for KOOS-QoL and ACL-QoL, while the lower-limb focussed intervention had potentially greater effects for KOOS-Sport, KOOS-Pain, and functional performance. CONCLUSIONS: A larger-scale RCT is warranted. All feasibility criteria were met, or reasonable recommendations could be made to achieve the criteria in future trials. Strategies to increase recruitment rate and exercise adherence are required. The potential worthwhile effects for knee-related QoL, symptoms, and function indicates a fully-powered RCT may detect a clinically meaningful effect. TRIAL REGISTRATION: Prospectively registered ( ACTRN12616000564459 ).

Limb symmetry index on a functional test battery improves between one and five years after anterior cruciate ligament reconstruction, primarily due to worsening contralateral limb function.

OBJECTIVE: Evaluate change in functional performance from 1- to 5-years after anterior cruciate ligament reconstruction (ACLR). METHODS: 59 participants (38 men) aged 29 ± 16 years completed three hops and one-leg rise 1- and 5-years following ACLR. Linear mixed-effects models evaluated differences in change between the ACLR and contralateral limbs. Participants were classified with stable, improving or worsening function relative to previously published minimal detectable change thresholds. Healthy controls completed the three hops (n = 41) and one-leg rise (n = 31) as reference data. RESULTS: The contralateral limb had a significantly greater decrease in functional performance between 1- and 5-years for the three hops, compared to the ACLR limb. Worsening was more common in the contralateral limb than the ACLR limb; resulting in significant improvements in the LSI for the single hop (mean 87% at 1-year to 95% at 5-years), side hop (77%to 86%) and one-leg rise (76% to85%). Performance of both ACLR and contralateral limbs and the LSI remained below the healthy controls. CONCLUSION: Functional performance changes differ between limbs between 1- and 5-years post-ACLR. The LSI should not be used in isolation to evaluate functional performance changes after ACLR, as it may overestimate functional improvement, due to worsening contralateral limb function.

Making football safer for women: a systematic review and meta-analysis of injury prevention programmes in 11 773 female football (soccer) players.

OBJECTIVE: To evaluate the effects of injury prevention programmes on injury incidence in any women's football code; explore relationships between training components and injury risk; and report injury incidence for women's football. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Nine databases searched in August 2019. ELIGIBILITY CRITERIA: Randomised controlled trials evaluating any injury prevention programme (eg, exercise, education, braces) were included. Study inclusion criteria were: ≥20 female football players in each study arm (any age, football code or participation level) and injury incidence reporting. RESULTS: Twelve studies, all in soccer, met inclusion criteria, with nine involving adolescent teams (aged <18 years). All studies (except one) had a high risk of bias. Eleven studies examined exercise-based programmes, with most (9/11) including multiple (≥2) training components (eg, strength, plyometric, balance exercises). Multicomponent exercise programmes reduced overall (any reported) injuries (incidence rate ratio (IRR) 0.73, 95% CI 0.59 to 0.91) and ACL injuries (IRR 0.55, 95% CI 0.32 to 0.92). For exercise-based strategies (single-component and multicomponent), hamstring injuries were also reduced (IRR 0.40, 95% CI 0.17 to 0.95). While exercise-based strategies resulted in less knee, ankle and hip/groin injuries, and the use of multiple training components was associated with greater reductions in overall and knee injuries, further studies would be required to increase the precision of these results. The incidence of overall injuries in women's football was 3.4 per 1000 exposure hours; with ankle injuries most common. CONCLUSION: In women's football, there is low-level evidence that multicomponent, exercise-based programmes reduce overall and ACL injuries by 27% and 45%, respectively. PROSPERO REGISTRATION NUMBER: CRD42018093527.