Athletes' perspectives on return to sport after anterior cruciate ligament reconstruction and their strategies to reduce reinjury risk: a qualitative interview study.

BACKGROUND: Insights derived from athletes who have completed the final phase of rehabilitation and successfully returned to their respective sports after anterior cruciate ligament (ACL) reconstruction could potentially contribute to the enhancement of therapeutic strategies. Therefore, the aim of this study was to explore athletes' experiences, thoughts, and behaviours of final phase rehabilitation and return to sport after ACL reconstruction and to describe their thoughts about the risk of reinjury. METHODS: This qualitative interview study included individual semi-structured interviews with 15 athletes after ACL reconstruction. All athletes were aged between 15 and 35 years (median, 23 years), had returned to their preinjury contact sport at elite or recreational competitive level, rehabilitated with different physioterapists (working in hospital, primary care or sport clinics), and had undergone primary ACL reconstruction between 14 and 59 months (median, 23 months) before the interviews. Data were analysed using qualitative content analysis. RESULTS: Analysis of the data resulted in the following 4 main categories related to athletes' experiences of the return to sport process and their thoughts about the risk of reinjury: Athletes' strategies for safe return to sport; Support during rehabilitation and return to sport; The rehabilitation journey was worthwhile to be able to play again; and Reinjury is beyond one's control. CONCLUSIONS: Athletes described strategies for a safe return to sport after ACL reconstruction, emphasizing continuous increased load, not forcing return to sport, injury prevention exercises, and seeking support from professionals and coaches. Despite loving their sport, the athletes had mixed feelings about undergoing additional rehabilitation if reinjured. The athletes recognized the high reinjury risk, attributing it to fate. These findings enhance understanding of athletes' return to sport experiences after ACL reconstruction, their strategies to minimize reinjury risk, which might help optimizing care for this patient group.

Self-reported knee function and activity level are reduced after primary or additional anterior cruciate ligament injury in female football players: a five-year follow-up study.

BACKGROUND: Playing football involves a high risk of anterior cruciate ligament (ACL) injuries and these may affect knee function and activity level. OBJECTIVES: To measure changes in self-reported knee function, activity level, and satisfaction with knee function and activity level in female football players with or without an ACL-reconstructed knee. METHODS: Female football players, age 19.9 (SD 2.6) years, with either a primary ACL-reconstruction 1.6 (SD 0.7) years after ACL-reconstruction (n = 186) or no ACL injury (n = 113) were followed prospectively for five years. Self-reported data collected at baseline and follow-up included knee function (International Knee Documentation Committee Subjective Knee Form [IKDC-SKF]), activity level (Tegner Activity Scale), and satisfaction with knee function (Likert scale 1=happy; 7=unhappy) and activity level (1-10 scale). Information on any new ACL injury during the follow-up period was collected. RESULTS: Players with ACL-reconstruction at baseline who either did (n = 56) or did not (n = 130) sustain an additional ACL injury, and players with no injury at baseline who remained injury free (n = 101) had a lower Tegner score at follow-up. Players with additional ACL injury had lower IKDC-SKF score (mean difference: -11.4, 95% CI: -16.0, -6.7), and satisfaction with activity level (mean difference: -1.5, 95% CI: -2.3, -0.7) at follow-up. Players with no additional ACL injury had higher satisfaction with knee function (mean difference: 0.6, 95% CI: 0.3, 0.9) at follow-up. Players with no ACL injury had lower satisfaction with activity level (mean difference: -0.7, 95% CI: -1.1, -0.3) at follow-up. Players with additional ACL injury had larger decreases in all variables measured compared to the two other groups. CONCLUSION: Primary, and even more so additional, ACL injuries decreased self-reported knee function, activity level, and satisfaction with knee function and activity level in female football players.

Are We Jumping to the Wrong Conclusions? Longer Jumps and More Hops in Female Football Players Who Went on to Sustain a Primary or Secondary ACL Injury Compared to Those Who Did Not.

BACKGROUND: Different functional performance tests are used to assess patients in the clinic and before return to sport (RTS), where the rehabilitation goal is to reach good strength and jumping ability. A limb symmetry index of ≥ 90% is a common target in rehabilitation before RTS. The aim of this short communication is to use data from our 2-year prospective cohort study on female football players, either with or without an anterior cruciate ligament (ACL) reconstruction, to discuss whether hop performance in 3 commonly used hop tests can inform safe football participation, that is, with a low risk for ACL injury or reinjury. METHOD: At baseline, 117 active female football players (mean age ± standard deviation, 20 ± 2 years) were included 19 ± 9 months after ACL reconstruction as well as 119 matched female knee-healthy players (age 19 ± 3 years). All players performed a single hop for distance test, 5-jump test and side hop test at baseline and were then prospectively followed for 2 years. Twenty-eight (24%) players sustained a second ACL injury and 8 (7%) sustained a primary ACL injury. RESULTS: Longer jumps in the 5-jump test (922 cm vs. 865 cm, Cohen's d = - 0.60) and more hops in the side hop test for both limbs (41-42 hops vs. 33-36 hops, d = - 0.43 to - 0.60) were seen in players who sustained a second ACL injury compared with those who did not. Longer jumps in the single hop for distance test (both limbs) (139-140 cm vs. 124-125 cm, d = - 0.38 to - 0.44), in the 5-jump test (975 cm vs. 903 cm, d = -0.42) and more hops in the side hop test (both limbs) (48-49 hops vs. 37-38 hops, d = - 0.38 to - 0.47) were seen in players who sustained a primary ACL injury compared with those who did not. CONCLUSIONS: The average hop performance, i.e. longer jumps or more hops, was greater in players who went on to sustain a primary or secondary ACL injury compared to those who did not over a two-year follow-up period. Even though hop tests are not used in isolation to evaluate readiness to RTS, their interpretation needs consideration in the decision-making process of returning to pivoting sports.

Poorer patient-reported knee function and quality of life, but not activity level, after revision ACL reconstruction compared with primary ACL reconstruction: a matched-pair analysis with a minimum 5-year follow-up.

BACKGROUND: An appropriate method for comparing knee function and activity level between patients with primary and revision anterior cruciate ligament reconstruction (ACLR) is to perform a matched-group analysis. The aim was to assess and compare knee function, knee-related quality of life and activity level between patients with revision ACLR and primary ACLR at a minimum of 5 years of follow-up. METHODS: Patients aged ≤ 40 years old who underwent revision ACLR between 2010 and 2015 and a matched control group (primary ACLR) (1:1) with age ± 2 years, year of ACLR, sex, and pre-injury sport and Tegner Activity Scale (TAS) were retrospectively identified in our clinic database. The preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) and surgical data were extracted and analyzed. Patients were mailed KOOS and EQ-5D questionnaires at a minimum of 5-years after revision ACLR. Study-specific questions about knee function, limitation in sport, satisfaction, and activity level according to the TAS (all scales of 1-10, 10 best) were also asked by telephone. RESULTS: Seventy-eight patients with a revision ACLR (mean age ± SD, 29.9 ± 6.0 years) matched with seventy-eight patients with a primary ACLR (30.2 ± 5.8 years) were included. The follow-up for the revision ACLR group was 7.0 ± 1.5 years and for the primary ACLR group 7.7 ± 1.6 years. The revision ACLR group reported poorer KOOS scores in all subscales (p < 0.05) except the Symptoms subscale, poorer EQ-5D VAS (mean 79.2 ± 20.1 vs 86.0 ± 20.1, p = 0.012), and less satisfaction with current knee function (median 7 (6-8) vs 8 (7-9), p < 0.001). Patients with revision ACLR also experienced greater limitation in sports (median 7 (4-8) vs 8 (6-9), p < 0.001). There were no significant differences in the EQ-5D (mean 0.86 ± 0.17 vs 0.89 ± 0.11, p = 0.427), activity level (median 2 (2-5) vs 4 (2-7), p = 0.229), or satisfaction with activity level (median 8 (5-9) vs 8 (6-10), p = 0.281) between the groups. CONCLUSIONS: At a minimum 5-year follow-up, the revision ACLR group reported poorer knee function and quality of life, less satisfaction with knee function and a greater limitation in sports but no differences in activity level and satisfaction with activity level compared with the primary ACLR group.

The side hop test: Validity, reliability, and quality aspects in relation to sex, age and anterior cruciate ligament reconstruction, in soccer players.

OBJECTIVE: To study the side hop test regarding validity, reliability, and quality in relation to sex, age and ACL-reconstruction in soccer players. DESIGN: Cohort study. PARTICIPANTS: 117 females with a primary ACL-reconstruction, and 119 females, 46 males (age 16-26 years), 49 girls and 66 boys (age 13-16 years) without injury. MAIN OUTCOME MEASURES: For convergent validity, one physiotherapist analysed side hops live and later on video. One physiotherapist and two physiotherapy students analysed side hops from 92 players for interrater reliability (video). For intrarater reliability, side hops from 35 players were analysed twice (video). Quality aspects (flaws), i.e. number of times the hopping limb touched the strips, the non-hopping limb touched the floor, and double hops/foot turns with the hopping limb, were registered (video). RESULTS: Convergent validity was excellent; the intraclass correlation coefficient (ICC) was 0.93-1.0. All reliability measures were excellent (ICC 0.92-1.0). Adult male players had fewest and girls had most flaws, especially double hops/foot turns with the hopping limb, compared with all other players (mean, 11-12 vs 1-6, η2 = 0.18, large effect size). No differences were reported between knee-healthy and ACL-reconstructed females. CONCLUSION: The side hop test is valid and reliable. Quality aspects differ between sexes and ages.

Risk Factors for Sustaining a Second ACL Injury after Primary ACL Reconstruction in Female Football Players: A Study Investigating the Effects of Follow-Up Time and the Statistical Approach.

BACKGROUND: Studies evaluating risk factors for sustaining an anterior cruciate ligament (ACL) injury have different, sometimes contrasting, results. Different follow-up times and statistical approaches may be a reason for these differences. The aim of this study was to explore if different follow-up times and statistical approaches, classification and regression tree (CART) analysis and Cox regression, would impact on the association between various candidate risk factors and ACL injury in female football players. In total, 112 active female football players, 18 ± 8 months after ACL reconstruction (mean age ± SD, 20 ± 2 years), were included and followed for at least 36 months. At baseline, all players underwent assessment of range of motion of knee and ankle joints, functional tests, and answered questionnaires regarding knee function, psychological and personality traits. Nineteen independent variables were included for the CART analysis and for univariable Cox regression and compared using four different follow-up times: 0-12, 0-24, 0-36, and 0->36 months. RESULTS: Forty-three (38%) players sustained a second ACL injury. The identified risk factors varied depending on follow-up time both with CART analysis and with Cox regression. CART identified 12 of the 19 independent variables and selected between 5 and 6 of the variables in the four different follow-up times associated with second ACL injury. The accuracy of the different follow-up times for the CART varied between 86 and 93% with 77-96% sensitivity and 70-81% specificity. Cox regression identified two risk factors: knee extension at 0-36 months and 0->36 months, and time between primary injury and surgery at 0->36 months. The accuracy varied between 54 and 64% with 44-88% sensitivity and 32-71% specificity. CONCLUSIONS: The identified risk factors associated with a second ACL injury varied depending on the follow-up time and statistical approach used. Thus, in future research on risk factors, the time athletes are followed up and the type of statistical methods used are important to discuss.

Lifestyle characteristics in adolescent female football players: data from the Karolinska football Injury Cohort.

BACKGROUND: Normative values of lifestyle characteristics in adolescent female football players may be used by clinicians and coaches to take actions because the potential important for well-being, performance on the pitch, and risk of injury. The aim was to report descriptive characteristics of lifestyle factors in adolescent female football players and potential changes over 1 year. METHODS: We included 419 adolescent competitive female football players from 12 clubs and 27 teams (age 14 ± 1 years, range 12-17 years) and 286 were followed over 1 year. The players completed an extensive questionnaire regarding demographics, football-related factors, and lifestyle factors including tobacco consumption, alcohol use, medicine intake, eating and sleeping habits, well-being, stress, coping, and passion. Baseline data are presented for the total cohort and separately for 4 age groups (12, 13, 14, and 15-17 years). RESULTS: 12% skipped breakfast, 8% skipped lunch and 11% used protein supplements several days per week. 16% slept less than 8 h/night, 8% had impaired sleep with daytime consequences, and 22% stated that they were tired in daily activities several days per week. 32% experienced stress some or most days/week and 24% were classified as having psychological distress. Medicine intake (23% vs. 34%), skipping breakfast or lunch several days per week (10% vs. 47% and 20 vs. 33%), tiredness (20% vs. 27%), stress (26% vs. 40%), and psychological distress (27% vs. 37%) increased significantly (P = 0.031 to < 0.001) at the 1-year follow-up. CONCLUSION: Many adolescent female football players skip breakfast and lunch, have insufficient sleep, experience stress and are classified as having psychological distress. These factors increased over 1 year.

Normative values and changes in range of motion, strength, and functional performance over 1 year in adolescent female football players: Data from 418 players in the Karolinska football Injury Cohort study.

OBJECTIVE: To study normative values of range of motion (ROM), strength, and functional performance and investigate changes over 1 year in adolescent female football players. DESIGN: Cross-sectional. PARTICIPANTS: 418 adolescent female football players aged 12-17 years. MAIN OUTCOME MEASURES: The physical characteristic assessments included (1) ROM assessment of the trunk, hips, and ankles; (2) strength measures (maximal isometric and eccentric strength for the trunk, hips, and knees, and strength endurance for the neck, back, trunk and calves), and (3) functional performance (the one-leg long box jump test and the square hop test). RESULTS: Older players were stronger, but not when normalized to body weight. Only small differences in ROM regarding age were found. ROM increased over 1 year in most measurements with the largest change in hip external rotation, which increased by 6-7° (Cohen's d = 0.83-0.87). Hip (d = 0.28-1.07) and knee (d = 0.38-0.53) muscle strength and the square hop test (d = 0.71-0.99) improved over 1 year. CONCLUSIONS: Normative values for ROM and strength assessments of neck, back, trunk, hips, knees, calves and ankles are presented for adolescent female football players. Generally, fluctuations in ROM were small with little clinical meaning, whereas strength improved over 1 year.

Comparison of Knee Function and Activity Level Between Bilateral and Unilateral ACL Reconstruction: A Matched-Group Analysis With Minimum 5-Year Follow-up.

Background: There is a lack of knowledge regarding knee function and activity level after bilateral anterior cruciate ligament reconstruction (ACLR) at midterm follow-up. Purpose: To compare activity level, patient-reported knee function, and quality of life in patients with bilateral ACLR and matched controls with unilateral ACLR at a minimum 5-year follow-up. Study Design: Cohort study; Level of evidence, 3. Methods: Patients with bilateral ACLR who were aged ≤40 years and had a second ACLR performed between 2010 and 2015 were identified in the authors' local database. Surgical data and preoperative Knee injury and Osteoarthritis Outcome Score (KOOS) were extracted. The patients were sent a letter with questionnaires including the KOOS, EuroQol 5-Dimensions (EQ-5D), and EuroQol visual analog scale (EQ-VAS) and were asked study-specific questions by telephone regarding activity level and knee function at a minimum 5-year follow-up. For every patient with bilateral ACLR, a control matched for age ±2 years, sex, year ACLR was performed, and preinjury activity level or sport at the time of injury were identified in the database. Results: A total of 98 patients (mean age ± SD, 33.3 ± 7.3 years) with bilateral ACLR and 98 patients with unilateral ACLR (mean age ± SD, 33.1 ± 7.7 years) were included. The mean postoperative follow-up was 7.6 ± 1.8 years (from the second ACLR) for patients with bilateral ACLR and 7.8 ± 1.7 years for patients with unilateral ACLR. Patients with bilateral ACLR reported lower scores on all KOOS subscales, the EQ-5D, and the EQ-VAS at follow-up (P < .05). There was no difference in activity level between the groups at follow-up, but patients with bilateral ACLR were less satisfied with their activity level and knee function (P < .05). Conclusion: Patient-reported knee function and health-related quality of life were inferior in patients with bilateral ACLR compared with patients with unilateral ACLR. Patients with bilateral ACLR cannot expect the same knee function and quality of life as patients with unilateral ACLR.

Neuromuscular control and hop performance in youth and adult male and female football players.

OBJECTIVES: To compare neuromuscular control and hop performance between youth and adult male and female football players. DESIGN: Cross-sectional study. PARTICIPANTS: 119 youth players (13-16 years; 68 males) and 88 adult players (17-26 years; 44 males). MAIN OUTCOME MEASURES: Neuromuscular control assessed with drop vertical jump (DVJ) and tuck jump assessment (TJA). Hop performance assessed with single-leg hop for distance and side hop. RESULTS: Adult females had smaller normalized knee separation distances (NKSD) during DVJ at initial contact (77.9 ± 18.5 vs. 86.1 ± 11.0, p = 0.010) and at maximum knee flexion (59.7 ± 23.4 vs.74.1 ± 18.1, p = 0.001) compared to youth females. TJA revealed more technique errors in youths compared to adults (males 10 (8-11) vs. 8 (7-10); females 11 (9-12) vs. 9 (8-11), p < 0.05). Youths demonstrated inferior hop performance (males single-leg hop 142 ± 18 vs. 163 ± 17, side hop 41 ± 12 vs. 52 ± 12, p < 0.001; females side hop 32 ± 10 vs. 38 ± 14, p < 0.05). CONCLUSIONS: Youth players demonstrated reduced neuromuscular control during TJA and inferior hop performance compared to adult players. Adult female players demonstrated greater knee valgus during DVJ compared to youth female players.

High Risk of New Knee Injuries in Female Soccer Players After Primary Anterior Cruciate Ligament Reconstruction at 5- to 10-Year Follow-up.

BACKGROUND: A new anterior cruciate ligament (ACL) injury after ACL reconstruction is a feared outcome. PURPOSE: To study the risk of new knee injuries in female soccer players 5 to 10 years after primary unilateral ACL reconstruction and to compare players who returned to soccer with (1) players who did not return and (2) knee-healthy soccer players (controls). STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Demographic, soccer-specific, and surgical data were recorded at baseline for 317 female soccer players (mean ± SD age, 20.1 ± 2.7 years) 1.6 ± 0.7 years after ACL reconstruction and for 119 matched controls (mean age, 19.5 ± 2.5 years). Data on new knee injuries and soccer-playing status were collected 5 to 10 years after ACL reconstruction via a questionnaire. RESULTS: Among players with ACL reconstruction, 222 (70%) responded at a mean 6.5 ± 1.0 years after primary ACL reconstruction. We compared 3 cohorts: (1) among 163 players with ACL reconstruction who returned to soccer, 68 (42%) sustained 44 reruptures and 29 contralateral ruptures; (2) among 59 players with ACL reconstruction who did not return to soccer, 11 (19%) sustained 9 reruptures and 2 contralateral ruptures; and (3) among 113 knee-healthy controls, 12 (11%) sustained 13 ACL injuries. Players who returned had a >2-fold higher risk of a new ACL injury than players who did not return (risk ratio, 2.24; 95% CI, 1.27-3.93; P = .005) and a 4-fold higher risk than controls (risk ratio, 3.93; 95% CI, 2.23-6.91; P <.001). A new ACL, meniscal, or cartilage injury was the most frequent new knee injury. Among players who returned to soccer, 68% reported a new knee injury, and they had a 2- to 5-times higher risk of any new knee injury and knee surgery than players who did not return and controls. CONCLUSION: Two-thirds of female soccer players with ACL reconstruction who returned to soccer sustained a new knee injury within 5 to 10 years; 42% had a new ACL injury. Their risk of a new knee injury and knee surgery was 2 to 5 times greater than that for players who did not return and for knee-healthy controls. New injury may have negative consequences for long-term knee health and should be a critical consideration in the decision to return to play.

Clinical Risk Profile for a Second Anterior Cruciate Ligament Injury in Female Soccer Players After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: The risk of a second anterior cruciate ligament (ACL) injury when participating in pivoting sports after ACL reconstruction is high. Risk factors associated with a second ACL injury are complex. PURPOSE: To investigate the combinations of various clinical risk factors associated with second ACL injury in female soccer players with a primary unilateral ACL reconstruction, using Classification and Regression Tree (CART) analysis. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 117 active female soccer players (mean ± SD age, 20 ± 2 years) were included. Athletes were enrolled 19 ± 9 months after ACL reconstruction and were prospectively followed for 2 years. At baseline, all players underwent assessment of knee and ankle joint range of motion (ROM), participated in functional tests (postural control, hop performance, and movement asymmetries in the lower limbs and trunk), and answered questionnaires (patient-reported knee function, knee-related quality of life, psychological and personality factors). A clinical prediction model using CART was developed. RESULTS: A total of 28 players (24%) sustained a second ACL injury (21 ipsilateral and 7 contralateral ruptures) while playing soccer. CART analysis selected 9 of 19 independent variables associated with second ACL injury: the 5-jump test, knee collapse on the non-ACL reconstructed leg in a drop vertical jump, tuck jump, limb symmetry index on side hop and the single hop for distance, side difference in ankle dorsiflexion ROM, and scores for the questionnaires ACL-Return to Sport After Injury and the Swedish Universities Scales of Personality subscales of Stress Susceptibility and Adventure Seeking. The accuracy of the model was 89%, with 100% sensitivity and 76% specificity. CART analysis indicated that the interaction of longer jumps in the 5-jump test (>916 cm) with more side difference in ankle dorsiflexion ROM (>-2.5°) and more knee valgus collapse in the nonreconstructed knee (>-1.4 cm) (relative risk, 4.03; 95% CI, 2.21-7.36) best predicted an increased likelihood of a second ACL injury. CONCLUSION: The risk profiles selected by CART could accurately identify female soccer players at high risk for a second ACL injury. There was an interaction between functional performance, clinical assessment, and psychological factors, and it is reasonable to include these factors in return-to-sport decisions and in athlete screening after ACL injury.

Poor Validity of Functional Performance Tests to Predict Knee Injury in Female Soccer Players With or Without Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Various tests have been developed to evaluate athletes' functional performance and for use as screening tools for injury prediction. Further validation of their accuracy to predict injury is needed. PURPOSE: To investigate the validity of predetermined cutoffs used to differentiate between high- and low-risk players in different functional performance tests to predict (1) anterior cruciate ligament (ACL) injury or (2) severe traumatic knee injury in a cohort of female soccer players with a primary unilateral ACL reconstruction and a cohort of knee-healthy players. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 117 active female soccer players (mean age ± SD, 20 ± 2 years) an average of 19 ± 9 months after ACL reconstruction and 119 knee-healthy players (age, 19 ± 3 years) were prospectively followed up for 2 years for new knee injuries. At baseline, all players underwent tests to assess postural control (Star Excursion Balance Test), hop performance (single-leg hop for distance, side hop), and movement asymmetries in the lower limbs and trunk (drop vertical jump [DVJ], tuck jump). The predictive validity of the test cutoffs to identify players who would sustain an ACL injury or a severe traumatic knee injury (absence from soccer play, >28 days) was assessed. The risk ratio (RR), area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were calculated. RESULTS: A total of 46 players (39%) with ACL reconstruction sustained 48 severe knee injuries, including 28 ACL ruptures. Of the knee-healthy players, 13 (11%) sustained 14 severe knee injuries, including 8 ACL ruptures. No association was found between the predetermined functional performance test cutoffs and the risk of a new ACL injury or severe knee injury in players with ACL reconstruction. In knee-healthy players, the only variable associated with future ACL injury was ≥6.5 cm knee valgus in the frontal plane (any knee) in the DVJ (RR, 4.93; 95% CI, 1.04-23.40; P = .045), but with only fair predictive validity (AUC, 0.7; sensitivity, 0.75; specificity, 0.65). CONCLUSION: In our cohorts of female soccer players, the validity of commonly used functional performance tests to predict new knee injuries was poor. Only knee valgus during the DVJ was associated with new ACL injuries in knee-healthy players, but with only fair predictive validity.

TUCK JUMP SCORE IS NOT RELATED TO HOPPING PERFORMANCE OR PATIENT-REPORTED OUTCOME MEASURES IN FEMALE SOCCER PLAYERS.

BACKGROUND: The tuck jump assessment was developed to identify players at risk for anterior cruciate ligament (ACL) injuries or gauge a player's progress through rehabilitation after ACL reconstruction. A tuck jump score of ≥ 6 out of 10 has been labeled poor and thought to identify players with high risk landing patterns. PURPOSE: The purpose of this exploratory study was to examine if there was a relationship between tuck jump score, particularly tuck jump scores ≥ 6, hopping performance, and patient-reported outcome measures in female soccer players with ACL reconstruction (ACLR) and knee-healthy controls. STUDY DESIGN: Secondary analysis of prospective cohort study. METHODS: Female soccer players (117 after ACLR, 117 knee-healthy) performed the single hop for distance, tuck jump assessment, and drop vertical jump (DVJ). All players were categorized based on as having a total tuck jump score ≥ 6 or < 6. Analyzing all players together, Spearman's rank correlations assessed if there were relationships between total tuck jump score or tuck jump scores ≥ 6 and single-legged hop limb symmetry or DVJ measures. Players with an ACLR also filled out the International Knee Documentation Committee 2000 Subjective Knee Form and the Knee injury Osteoarthritis Outcome Score. Spearman's rank correlations assessed if there were relationships between total tuck jump score or tuck jump scores ≥ 6 and patient-reported outcome measures. RESULTS: The mean tuck jump scores was 4.8 ± 1.8 (tuck jump score ≥ 6, 6.7 ± 0.9, tuck jump score < 6, 3.7 ± 1.1) with 87 (37%) athletes having tuck jump score ≥ 6. There were no significant relationships between tuck jump score or tuck jump score ≥ 6 and hopping performance or patient-reported outcome measures. CONCLUSION: The results of this current study indicate that tuck jump scores, including tuck jump scores ≥ 6, may not be related to functional or patient-reported outcome measures. Further work is needed to examine the clinical utility of the tuck jump assessment. LEVEL OF EVIDENCE: 2.

PATIENTS FOCUS ON PERFORMANCE OF PHYSICAL ACTIVITY, KNEE STABILITY AND ADVICE FROM CLINICIANS WHEN MAKING DECISIONS CONCERNING THE TREATMENT OF THEIR ANTERIOR CRUCIATE LIGAMENT INJURY.

BACKGROUND: When deciding medical treatment, patients' perspectives are important. There is limited knowledge about patients' views when choosing non-operative treatment or anterior cruciate ligament (ACL) reconstruction (ACLR) after ACL injury. PURPOSE: To describe reasons that influenced patients' decisions for non-operative treatment or ACLR after ACL injury. STUDY DESIGN: Cross-sectional study. METHODS: This study recruited a total of 223 patients (50% men), aged 28 ± 8 years who had sustained ACL injury, either unilateral or bilateral. Subjects were, at different time points after injury, asked to fill out a questionnaire about their choice of treatment, where an ACLR treatment decision was made, some responded before and some after the ACLR treatment. A rating of the strength of 10 predetermined reasons in their choice of treatment graded as 0 (no reason) to 3 (very strong reason), was done. RESULTS: Patients with unilateral ACL injury treated with ACLR (110 patients) rated "inability to perform physical activity at the same level as before the injury due to impaired knee function" (96%), "fear of increased symptoms during activity" (87%) and "giving way episodes" (83%) as strong or very strong reasons in their treatment decision. Patients with bilateral ACL injury treated with ACLR (109 knees) rated similar reasons as patients with unilateral ACLR and also "low confidence in the ability to perform at the preinjury activity level without ACLR" (80%) as strong or very strong reasons. Patients with unilateral ACL injury treated non-operatively (46 patients) rated "advice from clinician" (69%) as a strong or very strong reason. Patients with bilateral ACL injury treated non-operatively (25 knees) rated "absence of giving way episodes" (62%), and "no feeling of instability" (62%) as strong or very strong reasons. CONCLUSION: Inability to perform physical activity, fear of increased symptoms, and giving way episodes were reasons that patients with ACL injury considered when making decisions about ACLR. When choosing non-operative treatment, patients considered the absence of instability or giving way symptoms, being able to perform physical activity, and advice from clinicians. LEVEL OF EVIDENCE: 4.

Jump performance in male and female football players.

PURPOSE: To examine differences between men and women football players in clinically feasible jumping measures. METHODS: Female football players (N = 46, ages 16-25) were matched based on age, training frequency, and playing position with 46 male players. All players performed the tuck jump and drop vertical jump (DVJ). DVJ was assessed quantitatively for valgus knee motion and probability of a high peak knee abduction moment (pKAM), as well as sagittal plane hip, knee, and ankle angles, and qualitatively with visual assessment of the player's knees upon landing; graded as good, reduced, or poor control. RESULT: Women had higher total tuck jump scores (5 ± 2) (more technique flaws), than men (3 ± 2, P < 0.01). The quantitative analysis of the DVJ found that men had greater asymmetries between limbs, but women landed bilaterally in more knee valgus (interaction P = 0.04, main effect of sex P = 0.02). There was no difference in pKAM (interaction n.s.). Women also landed in less hip flexion (P = 0.01) and ankle dorsiflexion (P = 0.01) than men. The qualitative DVJ analysis found that more women (48%) had poor knee control compared to men (11%, P < 0.01). CONCLUSIONS: The results indicate that women perform worse on the tuck jump assessment than men. The results support previous findings that women land in more knee valgus than men, but also found that men may have larger asymmetries in knee valgus. These results from clinically feasible measures provide some suggestions for clinicians to consider during ACL reconstruction rehabilitation to enhance performance.

Female Soccer Players With Anterior Cruciate Ligament Reconstruction Have a Higher Risk of New Knee Injuries and Quit Soccer to a Higher Degree Than Knee-Healthy Controls.

BACKGROUND: Many patients with anterior cruciate ligament (ACL) reconstruction who return to sport suffer new ACL injuries or quit sports soon after returning. PURPOSE: To prospectively follow a cohort of female soccer players with primary unilateral ACL reconstruction and matched knee-healthy controls from the same soccer teams to compare (1) the rate of new traumatic and nontraumatic knee injuries and other injuries, (2) the proportion of players who quit soccer, and (3) player-reported activity level and satisfaction with activity level and knee function. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 117 active female soccer players (mean ± SD age, 19.9 ± 2.5 years) 18.9 ± 8.7 months after ACL reconstruction and 119 knee-healthy female soccer players (19.5 ± 2.5 years) matched from the same teams were prospectively followed for 2 years for new knee injuries, other injuries, soccer playing level, activity level according to the Tegner Activity Scale, and satisfaction with activity level and knee function. RESULTS: Players with ACL reconstruction had a higher rate of new ACL injuries (n = 29 vs 8; 19 vs 4 per 100 player years; rate ratio [RR], 4.82; 95% CI, 2.20-10.54; P < .001), other traumatic knee injuries (29 vs 16 per 100 player years; RR, 1.84; 95% CI, 1.16-2.93; P < .01), and nontraumatic knee injuries (33 vs 9 per 100 player years; RR, 3.62; 95% CI, 2.11-6.21; P < .001) as compared with controls. There was no difference in the rate of other (not knee) injuries (43 vs 48 per 100 player years; RR, 0.90; 95% CI, 0.65-1.23; P = .494). During the 2-year follow-up, 72 (62%) players with ACL reconstruction quit soccer, as opposed to 43 (36%) controls ( P = .001). The median Tegner Activity Scale score decreased in both groups ( P < .001) but more for the ACL-reconstructed group ( P < .015). CONCLUSION: Female soccer players with ACL reconstruction had nearly a 5-fold-higher rate of new ACL injuries and a 2- to 4-fold-higher rate of other new knee injuries, quit soccer to a higher degree, and reduced their activity level to a greater extent as compared with knee-healthy controls.

Jumping performance based on duration of rehabilitation in female football players after anterior cruciate ligament reconstruction.

PURPOSE: To determine if female football players who had longer durations of rehabilitation, measured in months, after anterior cruciate ligament reconstruction would have lower tuck jump scores (fewer technique flaws) and smaller asymmetries during drop vertical jump landing. METHODS: One-hundred-and-seventeen female football players, aged 16-25 years, after primary unilateral ACL reconstruction (median 16 months, range 6-39) were included. Athletes reported the duration of rehabilitation they performed after anterior cruciate ligament reconstruction. Athletes also performed the tuck jump and drop vertical jump tests. Outcome variables were: tuck jump score, frontal plane knee motion and probability of peak knee abduction moment during drop vertical jump landing. RESULTS: There was no difference in tuck jump score based on duration of rehabilitation (n.s.). No interaction (n.s.), difference between limbs (n.s.), or duration of rehabilitation (n.s.) was found for peak knee abduction moment during drop vertical jump landing. No interaction (n.s.) or difference between limbs (n.s.) was found for frontal plane knee motion, but there was a difference based on duration of rehabilitation (P = 0.01). Athletes with > 9 months of rehabilitation had more frontal plane knee motion (medial knee displacement) than athletes with < 6 months (P = 0.01) or 6-9 months (P = 0.03). CONCLUSION: As there was no difference in tuck jump score or peak knee abduction moment based on duration of rehabilitation, the results of this study press upon clinicians the importance of using objective measures to progress rehabilitation and clear athletes for return to sport, rather than time alone. LEVEL OF EVIDENCE: II.

Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction.

PURPOSE: The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients', roles are in the treatment decision. METHODS: A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients' preferences. RESULT: Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patient's wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patient's wishes as important for the decision to recommend ACL reconstruction. CONCLUSION: Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. LEVEL OF EVIDENCE: Diagnostic study: Level III.

Functional Performance Among Active Female Soccer Players After Unilateral Primary Anterior Cruciate Ligament Reconstruction Compared With Knee-Healthy Controls.

BACKGROUND: Good functional performance with limb symmetry is believed to be important to minimize the risk of injury after a return to pivoting and contact sports after anterior cruciate ligament reconstruction (ACLR). PURPOSE: This study aimed to investigate any side-to-side limb differences in functional performance and movement asymmetries in female soccer players with a primary unilateral anterior cruciate ligament (ACL)-reconstructed knee and to compare these players with knee-healthy controls from the same soccer teams. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This study included 77 active female soccer players at a median of 18 months after ACLR (interquartile range [IQR], 14.5 months; range, 7-39 months) and 77 knee-healthy female soccer players. The mean age was 20.1 ± 2.3 years for players with an ACL-reconstructed knee and 19.5 ± 2.2 years for controls. We used a battery of tests to assess postural control (Star Excursion Balance Test) and hop performance (1-legged hop for distance, 5-jump test, and side hop). Movement asymmetries in the lower limbs and trunk were assessed with the drop vertical jump and the tuck jump using 2-dimensional analyses. RESULTS: The reconstructed and uninvolved limbs did not differ in any of the tests. In the 5-jump test, players with an ACL-reconstructed knee performed worse than controls (mean 8.75 ± 1.05 m vs 9.09 ± 0.89 m; P = .034). On the drop vertical jump test, the ACL-reconstructed limb had significantly less knee valgus motion in the frontal plane (median 0.028 m [IQR, 0.049 m] vs 0.045 m [IQR, 0.043 m]; P = .004) and a lower probability of a high knee abduction moment (pKAM) (median 69.2% [IQR, 44.4%] vs 79.8% [IQR, 44.8%]; P = .043) compared with the control players' matched limb (for leg dominance). Results showed that 9% to 49% of players in both groups performed outside recommended guidelines on the different tests. Only 14 players with an ACL-reconstructed knee (18%) and 15 controls (19%) had results that met the recommended guidelines for all 5 tests ( P = .837). CONCLUSION: The reconstructed and uninvolved limbs did not differ, and players with an ACL-reconstructed knee and controls differed only minimally on the functional performance tests, indicating similar function. It is worth noting that many players with an ACL-reconstructed knee and controls had movement asymmetries and a high pKAM pattern, which have previously been associated with an increased risk for both primary and secondary ACL injury in female athletes.