Effectiveness of psychological intervention following anterior cruciate ligament reconstruction: A systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of psychological interventions in postoperative anterior cruciate ligament reconstruction (ACLR) compared to standard rehabilitation. METHODS: The databases searched were PubMed, MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, Cumulative Index to Nursing & Allied Health Literature, and EMBASE were searched from each database inception to May 2023 for published studies. The methodological quality was assessed with the Cochrane Risk of Bias Assessment (RoB 2.0) tool. The evidence quality was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. RESULTS: Six papers were included in the meta-analysis. Psychological intervention significantly improved Tampa Scale for Kinesiophobia at 3 months (Standard Mean Difference [SMD], -0.51. 95% Confidence Interval [CI], -0.85 to -0.17) and pain (Knee Injury and Osteoarthritis Outcome Score for Pain, Numeric Rating Scale, Visual Analog Scale) at 3 months (SMD, -0.92. 95%CI, -1.69 to -0.15) and at 6 months following ACLR (MD, -1.25. 95%CI, -1.82 to -0.68) when compared with the standard rehabilitation, according to very low-quality data. Self-efficacy and knee strength did not show significant differences. CONCLUSION: Very low-quality evidence suggests that psychological intervention following ACLR yields better short-term outcomes compared to standard rehabilitation, with uncertainty about its clinically significant benefits over standard rehabilitation.

From Control to Chaos: Visual-Cognitive Progression During Recovery from ACL Reconstruction.

BACKGROUND: Anterior cruciate ligament tear is a serious knee injury with implications for central nervous system (CNS) plasticity. To perform simple knee movements, people with a history of ACL reconstruction (ACL-R) engage cross-modal brain regions and when challenged with cognitive-motor dual-tasks, physical performance deteriorates. Therefore, people with ACL-R may increase visual-cognitive neural processes for motor control. CLINICAL QUESTION: What components of CNS plasticity should the rehabilitation practitioner target with interventions, and how can practitioners augment rehabilitation exercises to target injury associated plasticity? KEY RESULTS: This clinical commentary (1) describes the neurophysiological foundation for visual-cognitive compensation after ACL-R, (2) provides a theoretical rationale for implementing visual-cognitive challenges throughout the return to sport (RTS) continuum, and (3) presents a framework for implementing visual-cognitive challenges from the acute phases of rehabilitation. The 'Visual-Cognitive Control Chaos Continuum (VC-CCC) framework consists of five training difficulties that progress visual-cognitive challenges from high control to high chaos, to better represent the demands of sport. CLINICAL APPLICATION: The VC-CCC framework augments traditional rehabilitation so that each exercise can progress to increase difficulty and promote sensorimotor and visual-cognitive adaptation after ACL-R.

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

BACKGROUND: Return to sport (RTS) after treatment of an anterior cruciate ligament (ACL) tear is a critical parameter to assess the outcome of a surgical procedure. However, few studies have investigated RTS after ACL repair. PURPOSE: To evaluate RTS of a group of amateur soccer players at a minimum follow-up of 2 years after ACL repair. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of all patients treated with acute ACL repair was conducted. A total of 50 amateur soccer players were included in the study. Patients were examined clinically or contacted to complete postoperative patient-reported outcome measures, namely the Knee injury and Osteoarthritis Outcome Score, the International Knee Documentation Committee questionnaire, the ACL-Return to Sport After Injury scale, and the Forgotten Joint Score-12. RESULTS: The patients' mean age was 25.8 ± 7.7 years (range, 14-47 years), and the mean follow-up was 34.3 ± 10.7 months (range, 24-51.3 months). The median Tegner Activity Scale score was 9. The ACL repair failure rate was 16% (8/50). The mean time from repair to failure was 23.1 ± 12.7 months (range, 6-44 months), and the mean age of patients who sustained ACL repair failure was 19.9 ± 3.3 years (range, 14-24 years), significantly lower compared with patients who did not experience ACL repair failure (26.9 ± 7.9 years; range, 16-47 years; P = .017). Multivariate analysis showed that age ≤21 years was the only significant risk factor for ACL repair failure (odds ratio, 5.45; confidence interval, 1.24-27.91; P = .041). Excluding the 8 patients who experienced repair failure, 31 of 42 patients (73.8%) returned to soccer after ACL repair, with 29 of the 31 (93.5%) returning at their preinjury level of play. Moreover, patients who played competitive soccer and returned to their preinjury level of play were significantly younger than those who did not return to their preinjury level of play (mean, 21.1 ± 3.4 vs 29.2 ± 9.5 years, respectively; P = .002) and had significantly better ACL-Return to Sport After Injury scores (mean, 96.6 ± 4 vs 87.8 ± 11, respectively; P = .044). CONCLUSION: In this study, 73.8% (n = 31) of patients returned to playing soccer, of whom 93.5% (n = 29) returned to their preinjury level after ACL repair. The failure rate was 16% (n = 8) and mainly involved patients ≤21 years old.

Nurse-Assisted Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction.

Despite significant advancements in surgical instruments and operation skills, short- and long-term outcomes following anterior cruciate ligament reconstruction (ACLR) remain unsatisfactory, as many patients fail to return to their pre-injury level of sports. Inadequate ACL rehabilitation is the primary cause of poor outcomes. Nurses have become a crucial element in the rehabilitation process. Although there is no consensus regarding the optimal post-operative rehabilitation protocols, restoring muscle strength and neuromuscular control are consistently the primary goals. This literature review presents nurse-assisted rehabilitation protocols aiming at improving muscle strength and neuromuscular control. The review discusses postoperative rehabilitation, including home-based and supervised rehabilitation, open and closed kinetic chain exercises, eccentric and concentric training, blood flow restriction training, and plyometric training. Each training protocol has its benefits and drawbacks, and should be used cautiously in specific stages of rehabilitation. Neuromuscular training, such as neuromuscular electrical stimulation, neuromuscular control exercises, and vibration therapy, is considered crucial in rehabilitation.

The effect of factors from different time points on psychological readiness following ACL reconstruction.

OBJECTIVE: The purpose of this study was to examine factors correlated with psychological readiness to return to activity after ACLR. DESIGN: cross sectional study. SETTING: controlled laboratory. PARTICIPANTS: 164 patients (82 M/82 F, 22.5 ± 8.9yr, 171.6 ± 11.0 cm, 77.4 ± 18.6 kg, 8.6 ± 3.4 months post-ACLR) participated in this study after a primary, isolated, and uncomplicated ACLR. MAIN OUTCOME MEASURES: ACL Return to Sport Index (ACL-RSI). RESULTS: ACL-RSI scores demonstrated a weak positive correlation with activity level at the time of injury and a fair positive correlation with activity level at the time of post-operative testing (p-values: 0.004, <0.001). ACL-RSI scores showed a statistically significant fair negative correlation with pain and a moderate negative correlation with kinesiophobia during rehabilitation (p-values: <0.001, <0.001). There was no statistical significance between ACL-RSI and the surgical variables (p-value range: 0.10-0.61). CONCLUSIONS: Outcomes from testing during postoperative rehabilitation were most correlated with psychological readiness to return to activity after ACLR. Increased pain and kinesiophobia were associated with a decreased psychological readiness. Increased activity level prior to injury and activity level at the time of testing during rehabilitation were both correlated with increased psychological readiness. Psychological readiness to return to activity may need to be customized based on potentially modifiable patient-specific factors during the post-operative rehabilitation.

Multicomponent supervised tele-rehabilitation versus home-based self-rehabilitation management after anterior cruciate ligament reconstruction: a study protocol for a randomized controlled trial.

INTRODUCTION: Our study aims to assess the effectiveness of multicomponent supervised tele-rehabilitation compared to home-based self-rehabilitation management in patients following anterior cruciate ligament reconstruction (ACLR). METHODS: The current study is designed as a single-center, single-blinded, randomized controlled, two-arm trial. Participants will be randomized and allocated at a 1:1 ratio into either a multicomponent supervised tele-rehabilitation group or a home-based self-rehabilitation group. All participants receive uniform preoperative education through the HJT software. Participants in the intervention group undergo multicomponent supervised tele-rehabilitation, while those in the control group follow a home-based self-rehabilitation program. All the participants were assessed and measured for the included outcomes at the outpatient clinic before the procedure, and in 2, 4, 8, 12, and 24 weeks after ACLR by two assessors. The primary outcome was the percentage of patients who achieve a satisfactory active ROM at the 12 weeks following the ACLR. The satisfactory active ROM was also collected at 2, 4, 8, and 24 weeks after ACLR. The secondary outcomes were active and passive range of motion (ROM), pain, muscle strength, and function results. REGISTRATION DETAILS: Ethical approval has been obtained from the West China Hospital Ethics Committee (approval number 2023-1929, December 2023). The trial has been registered on ClinicalTrials.gov (registration number NCT06232824, January 2024).

Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT.

Background: Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. Objective(s): To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). Design: A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Setting: Twenty-nine NHS orthopaedic units in the United Kingdom. Participants: Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Interventions: Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. Main outcome measures: The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Results: Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Limitations: Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Conclusions: Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Future work: Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. Trial registration: This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

The study aimed to find out whether it is better to offer surgical reconstruction or rehabilitation first to patients with a more long-standing injury of their anterior cruciate ligament in their knee. This injury causes physical giving way of the knee and/or sensations of it being wobbly (instability). The instability can affect daily activities, work, sport and can lead to arthritis. There are two main treatment options for this problem: non-surgical rehabilitation (prescribed exercises and advice from physiotherapists) or an operation by a surgeon to replace the damaged ligament (anterior cruciate ligament reconstruction). Although studies have highlighted the best option for a recently injured knee, the best management was not known for patients with a long-standing injury, perhaps occurring several months previously. Because the surgery is expensive to the NHS (around £100 million per year), it was also important to look at the costs involved. We carried out a study recruiting 316 non-acute anterior cruciate ligament-injured patients from 29 different hospitals and allocated each patient to either surgery or rehabilitation as their treatment option. We measured how well they did with special function and activity scores, patient satisfaction and costs of treatment. Patients in both groups improved substantially. It was expected that some patients in the rehabilitation group would want surgery if non-surgical management was unsuccessful. Forty-one per cent of patients who initially underwent rehabilitation subsequently elected to have reconstructive surgery. Overall, the patients allocated to the surgical reconstruction group had better results in terms of knee function and stability, activity level and satisfaction with treatment than patients allocated to the non-operative rehabilitation group. There were few problems or complications with either treatment option. Although the surgery was a more expensive treatment option, it was found to be cost-effective in the UK setting. The evidence can be discussed in shared decision-making with anterior cruciate ligament-injured patients. Both strategies of management led to improvement. Although a rehabilitation strategy can be beneficial, especially for recently injured patients, it is advised that later-presenting non-acute and more long-standing anterior cruciate ligament-injured patients undergo surgical reconstruction without necessarily delaying for a period of rehabilitation.

Pattern of strength recovery differences Exist in Adolescent athletes after anterior cruciate ligament reconstruction when using quadriceps versus Hamstring tendon autograft.

OBJECTIVES: To compare the timeline for post-operative quadriceps and hamstrings strength recovery following anterior cruciate ligament reconstruction (ACLR) using either a quadriceps tendon (QT) or hamstring tendon (HT) autograft. METHODS: Patients (≤18 years) who underwent ACLR using autograft QT or HT were included. Isokinetic strength was extracted at 3, 6, and 12 months post-operatively. Effects of time and graft type on quadriceps or hamstring limb symmetry index (qLSI/hLSI) was assessed with two-way repeated measures ANOVA. Between group differences at each time point were assessed with unpaired t-tests. Chi-square and Kaplan-Meir analysis analyzed the proportions of subjects able to achieve ≥90% LSI. RESULTS: A total of 75 subjects (QT n = 38 HT n = 37,15.8 years) were included. There were significant differences in qLSI, with greater symmetry within the HT group at all time points. A higher proportion of subjects with HT grafts were able to achieve ≥90% qLSI within 12 months of surgery (81% vs 45%, p = 0.001). CONCLUSION: Compared to those with HT autografts, adolescents with QT autografts demonstrate a prolonged timeline for quadriceps recovery. While mean strength values above 90% are achieved, a significantly lower percentage of QT patients are able to achieve 90% qLSI by 12 months post-op.

Are demographics, physical function and psychological response associated with return to sport at one year following ACL-reconstruction?

OBJECTIVE: To determine the relative contribution of each of the following aspects: demographics, physical function, and patient-reported outcome measures (PROMs), including both physical and psychological constructs, to return to sport (RTS) (any level) one-year post anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional cohort study. METHODS: We included data for 143 participants (73 women, mean (SD) age 24 (5.8) years) âˆ¼ one-year post-ACLR. Data comprised demographics, physical function (hop performance, hip and knee peak torque) and PROMs (Knee Osteoarthritis Outcome Score subscales, perceived stress, and ACL Return to Sport after Injury scale (ACL-RSI)). We then used a Z-normalized multivariable logistic regression model to establish the relative contribution of factors associated with RTS. RESULTS: Sixty-four (45%) of the participants had returned to sport at one year post-ACLR. In the regression model, greater hip abduction peak torque (OR = 1.70, 95% CI; 1.01 to 2.84) and greater psychological readiness to RTS (OR = 2.32, 95% CI; 1.30 to 4.12) were the only variables associated with RTS (R2 = 0.352). CONCLUSIONS: The significant contribution of hip abduction strength and psychological readiness to RTS was still relatively small, suggesting other potential factors explaining RTS which may not be captured by common RTS criteria.

Return to running criteria after anterior cruciate ligament reconstruction: an online survey of 1404 Italian physiotherapists.

BACKGROUND: The aim of this study is to study the clinical decision-making practice of Italian physiotherapists in return to running (RTR) after anterior cruciate ligament (ACL) reconstruction, and the differences in decision-making in relation to physiotherapist's characteristics. METHODS: An online survey was developed, 1404 physiotherapists were contacted by email, via chartered association, or via social media. RESULTS: Most respondents (83%) indicated that the RTR decision should be made by a multidisciplinary team with RTR clearance around 3-4 months after surgery (47%). The most important criteria guiding the RTR decision were knee flexion range of motion (ROM) >130° (50%), complete extension ROM (95%), no pain (45%) and no effusion (68%). A Limb Symmetry Index (LSI) >70% for quadriceps (49%), hamstring (48%) and LSI >90% for posterolateral hip (45%) and triceps surae strength (42%) should be achieved for RTR. Approximately half of the participants (49%) do not consider ACL laxity tests to be used for RTR decisions. Response differences were found between sample subgroups. More experienced physiotherapists and those with post graduate training had lower thresholds to clear RTR. CONCLUSIONS: Experienced physiotherapists who treated a higher number of patients after ACL reconstruction, who had certified specialist training and a specific interest towards ACL rehabilitation, generally reported clinical practice modalities more in line with current evidence.

Return to sports after an ACL reconstruction in 2024 - A glass half full? A narrative review.

A successful return to sports (RTS) after an anterior cruciate ligament reconstruction (ACLR) is multifactorial, and therefore difficult and challenging. Unfortunately, low percentages of patients RTS, and for those who succeed, one-fifth of patients will sustain a second ACL injury. Over the past years, test batteries were developed to assess whether patients can RTS with a low risk for a second ACL injury risk. Low rates of patients who meet RTS criteria were found, coupled with the insufficiency of current RTS test batteries in predicting second ACL injuries suggesting poor sensitivity. The result of an RTS test is likely to reflect the content of a rehabilitation program, raising critical questions regarding what we are offering patients within the rehabilitation programme. Are we preparing our patients well enough for the high demands of complex situations within pivoting team sports? This narrative review offers insights from key lessons of the last 15 years on 1) RTS testing, 2) the content of rehabilitation, and 3) the RTS continuum, all from a "helicopter perspective".

Reasons for Not Returning to Pre-injury Sport Level After ACL-Reconstruction.

The study aimed to identify athlete-reported reasons for not returning to pre-injury sports level after anterior cruciate ligament reconstruction (ACLR) and to identify the factors associated with these reasons. Ninety-one athletes with 2 years post-ACLR indicated whether or not they had returned to their pre-injury sport level (same frequency, duration, and intensity). Athletes who did not return were asked to provide the reasons. Athletes' characteristics and injury-related factors were used to determine factors associated with the reasons for not returning. Only nine athletes (10%) returned to pre-injury sport level after ACLR. The most common reasons for not returning were lack of confidence or concerns about re-injury (48.8%), followed by continued post-surgical impairments in the reconstructed knee (39%). Having episodes of the knee giving way after ACLR was the only significant predictor of post-surgical impairments (48.8%; OR=8.3, 95%CI=2.48-27.42, p=0.001). Lack of confidence, concerns about re-injury, or post-surgical impairments in the reconstructed knee were the most frequently reported reasons for not returning to pre-injury sports level with 2 years post-ACLR. Reported dynamic knee instability was the only factor associated with ongoing post-surgical knee impairments after ACLR. Rehabilitation programs should address athletes' psychological responses and resolve knee impairments to optimize return to pre-injury sport level after ACLR.

Rehabilitation and return-to-sport after anterior cruciate ligament injury and reconstruction: Exploring physical therapists' approaches in Argentina.

OBJECTIVES: To investigate the current clinical practice regarding pre- and post-surgical rehabilitation and return to sport (RTS) criteria following anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional design. Online survey. SETTING: Survey platform. PARTICIPANTS: Argentinian physical therapists (PTs). OUTCOME MEASURES: The survey consisted of a combination of 39 open- and closed-ended questions, divided across 3 sections: (1) demographic and professional information, (2) clinical practice and rehabilitation strategies, and (3) return-to-running (RTR) and RTS. RESULTS: A total of 619 PTs completed the survey. Considerable variability was observed in preoperative rehabilitation, criteria used for rehabilitation progression and RTS decision-making criteria used by PTs. From the total surveyed, 336 (54.3%) carried out RTS assessment in their clinical practice. Most of PTs (53.3%) use visual estimation to assess knee range of motion. Only 20% of the PTs reported incorporating patient-reported outcome measures in their decision-making. From PTs who use strength assessment as a criterion of RTS (68.8%), 16.6% extrapolate this from jump tests and 15.3% use manual muscle testing. Less than the 50% of the PTs recommended nine months or more to allow patients to RTS. CONCLUSIONS: Current rehabilitation practices of Argentinian PTs following ACLR are largely variable and not aligned with current evidence and scientific guidelines. To achieve better rehabilitation and RTS practices better knowledge dissemination and implementation are required.

Test-retest reliability and longitudinal validity of drop vertical jump biomechanics during rehabilitation after ACL reconstruction.

Hip and knee biomechanics measured during a drop vertical jump (DVJ) can be used to assess patients undergoing rehabilitation after anterior cruciate ligament (ACL) reconstruction. To confidently interpret such data for use as outcome measures, additional information about reliability and validity is required. Therefore, the objective of this study was to estimate the test-retest reliability and longitudinal validity of selected lower limb biomechanics assessed during a DVJ in patients undergoing rehabilitation after ACL reconstruction. Biomechanical analysis of the DVJ in primary unilateral ACL reconstruction patients (22.3 ± 5.5y) were tested twice within 1 week at 6 months post-surgery (n = 46), and again at 12 months post-surgery (n = 36). Peak and initial contact knee angles and moments, hip impulse, vertical ground reaction forces (VGRF), isokinetic knee extension and flexion strength, and global ratings of change (GRC) were assessed. Reliability was evaluated based on the 6-month post-surgery data using intraclass correlation coefficients (ICC2,1), standard errors of measurement and minimum detectable change. Longitudinal validity was evaluated by assessing change from 6 to 12 months, using standardized response means (SRM), and by assessing the correlation (Pearson's r) of change in landing biomechanics with change in strength, and GRC. ICCs ranged from 0.58 to 0.90 for peak knee abduction and flexion moments, 0.44-0.85 for knee flexion and abduction angles, 0.82-0.93 for VGRFs, and 0.42-0.65 for hip impulse. SRMs and correlations of change ranged from 0.00 to 0.50. Reliability and longitudinal validity of DVJ measures varied, ranging from poor-to-excellent; the present results assist in their interpretation when assessed during rehabilitation after ACL reconstruction.

Effects of clamshell exercises in terminal extension lag after ACL reconstruction.

BACKGROUND: Terminal extension lag (TEL) is common following anterior cruciate ligament reconstruction (ACLR). Clamshell exercises have been suggested as a potential intervention to address TEL, but limited research has been conducted in this area. OBJECTIVE: This study aimed to determine the effects of Clamshell exercises in terminal extension lag after anterior cruciate ligament reconstruction. METHODS: This randomized controlled trial included 40 participants with a history of ACLR between 1 and 3 years prior. Participants were randomly assigned to either the experimental group (Group A) or the control group (Group B). Group A received conventional exercises along with isolated hip strengthening rehabilitation, while Group B received conventional exercises without specific hip strengthening. The primary outcomes were pain levels (Numeric Pain Rating Scale), knee function (International Knee Documentation Committee scores, (IKDC)), range of motions (goniometer) and strength (sphygmomanometer). RESULTS: In between the group comparison shows that all outcome measures (NPRS, IKDC, Goniometer, Sphygmomanometer) show significant results (p < 0.05). Within-group comparisons (paired sample t-test) show that there was a significant difference (p < 0.05) in all outcome measures of both groups. CONCLUSION: The addition of Clamshell exercises to the rehabilitation program resulted in a significantly greater reduction in TEL compared to the control group. These findings suggest that Clamshell exercises were found to be an effective intervention for addressing TEL after ACLR.

Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Are lower limb symmetry and self-reported symptoms associated with functional and neuromuscular outcomes in Brazilian adults with anterior cruciate ligament reconstruction? A cross-sectional study.

INTRODUCTION: After anterior cruciate ligament (ACL) reconstruction, determining readiness to return to participation is challenging. The understanding of which neuromuscular performance parameters are associated with limb symmetry and self-reported symptoms may be useful to improve monitoring the rehabilitation towards adequate decision-making to return. OBJECTIVES: To compare the ACL-operated and injury-free lower limbs regarding functional performance; and to investigate whether lower limb strength and functional performance are associated with self-reported symptoms and functional lower limb symmetry. METHOD: Thirty-four participants were included. Functional performance was assessed by using the Y-Balance test, Single-leg Hop, and Functional Movement Screen. An isokinetic dynamometer was used to evaluate the strength levels in open and closed kinetic chains. The functional lower limb symmetry was calculated considering the single-leg hop test results for each lower limb. RESULTS: There were no differences in dynamic balance (Y-Balance) between the operated and injury-free limbs. The operated limb presented a worst performance in the single-leg hop. Self-reported symptoms prevalence and lower limb symmetry were associated with knee extension strength and functional performance (Y-Balance). CONCLUSION: Individuals submitted to ACL-reconstruction presented worse functional performance in the operated limb compared to the injury-free limb. Both knee strength and dynamic balance were associated with limb symmetry and self-reported symptoms.