Return to Sport After Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Survey of The American Orthopaedic Society for Sports Medicine.

Introduction: Anterior cruciate ligament (ACL) tears are a common sports injury, and typically require a prolonged post-operative rehabilitation. The purpose of this study was to survey members of the American Orthopaedic Society for Sports Medicine (AOSSM) to determine their return to sport (RTS) criteria after primary ACL reconstruction (ACLR). Methods: A 23-question, anonymous survey hosted through Google® Docs was distributed electronically to AOSSM members. This survey included questions regarding the timing, as well as any functional tests or other metrics used to determine when an athlete is ready to RTS. Results: A total of 863 surgeons responded over four months. The most popular graft choice was bone patellar tendon bone autograft (63%). For non-pivoting sports, 43% of respondents allowed RTS at five to six months, while 31% allowed RTS at seven to eight months. For pivoting sports, 34% of respondents allowed RTS at seven to eight months, while 36% allowed RTS at nine to ten months. The most common criteria for return to non-pivoting sports include full knee motion (89%) and time after ACLR (76%). The most common criteria for return to pivoting sports include full knee motion (87%) and passing a hop test (80%). Only 21% of respondents assessed for psychological readiness to RTS. Conclusions: RTS occurred sooner in non-pivoting than pivoting sports, with similar RTS criteria in both groups. Most respondents did not assess for psychological readiness to RTS.

Weightbearing Protocols After Posterolateral Corner Reconstruction: A Systematic Review.

BACKGROUND: Multiligamentous knee injuries with a posterolateral corner injury represent a devastating insult to the knee. PURPOSE: To evaluate multiligamentous knee reconstruction rehabilitation programs and recommend a rehabilitation program based on a review of published outcomes studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A MEDLINE (PubMed), OVID, and Embase database search was conducted using the terms "posterolateral corner" and "rehabilitation." All articles obtained were examined to confirm their rehabilitation programs for multiligamentous knee injuries. These injuries included a posterolateral corner injury plus an isolated anterior or posterior cruciate ligament injury or a combined cruciate injury. RESULTS: Ten publications representing 245 patients with multiligamentous knee reconstruction were analyzed. Rehabilitation protocols were divided by weightbearing (WB) status: in 2 studies, patients were non-WB until postoperative 4 weeks (delayed WB; n = 61); 5 studies permitted progressive WB until postoperative 6 weeks (progressive WB; n = 123); and 3 studies allowed WB immediately after surgery (immediate WB; n = 61). No significant difference in outcome scores among the 3 WB groups was found. Arthrofibrosis requiring manipulation under anesthesia was the most common complication (11%) in the delayed WB group, followed by the immediate WB group (3%) and the progressive WB group (0%; P < .01). Overall complication rates were highest in the delayed WB group (44%), followed by the immediate and progressive WB groups (25% and 3%, respectively; P < .00001). The delayed WB group was permitted to return to sport at a mean of 10.5 months from the index procedure; the progressive WB group, at 6.0 months; and the immediate WB group, at 9.0 months (P < .05). CONCLUSION: This review revealed no significant difference in outcome scores when comparing immediate, progressive, and delayed WB protocols. Time to permitted return to sport was not significantly different among the groups, but there existed a trend toward earlier return in the progressive WB group. Patients in the delayed and immediate WB groups experienced a higher overall complication rate. Progressive WB postoperative protocols may decrease the risk of complications without compromising outcomes; however, more research is needed to identify the optimal postoperative rehabilitation protocol, given the significant data heterogeneity currently available in the literature.

Review of Variability in Rehabilitation Protocols after Lateral Ankle Ligament Surgery.

INTRODUCTION: Ankle sprains are one of the most common athletic injuries. If a patient fails to improve through conservative management, surgery is an option to restore ankle stability. The purpose of this study was to analyze and assess the variability across different rehabilitation protocols for patients undergoing either lateral ankle ligament repair, reconstruction, and suture tape augmentation. METHODS: Using a web-based search for published rehabilitation protocols after lateral ankle ligament repair, reconstruction, and suture tape augmentation, a total of 26 protocols were found. Inclusion criteria were protocols for post-operative care after an ankle ligament surgery (repair, reconstruction, or suture tape augmentation). Protocols for multi-ligament surgeries and non-operative care were excluded. A scoring rubric was created to analyze different inclusion, exclusion, and timing of protocols such as weight-bearing, range of motion (ROM), immobilization with brace, single leg exercises, return to running, and return to sport (RTS). Protocols inclusion of different recommendations was recorded along with the time frame that activities were suggested in each protocol. RESULTS: Twenty-six protocols were analyzed. There was variability across rehabilitation protocols for lateral ankle ligament operative patients especially in the type of immobilizing brace, time to partial and full weigh bearing, time to plantar flexion, dorsiflexion, eversion and inversion movements of the ankle, and return to single leg exercise and running. For repair and reconstruction, none of these categories had greater than 60% agreement between protocols. All (12/12) repair, internal brace, and unspecified protocols and 86% (12/14) of reconstruction protocols recommended no ROM immediately postoperatively. Eighty-six percent (6/7) of repair and 78% (11/14) of reconstruction protocols recommended no weight-bearing immediately after surgery, making post-operative ROM and weight-bearing status the most consistent aspects across protocols. Five protocols allowed post-operative weight-bearing in a cast to keep ROM restricted. Sixty-six percent (2/3) of suture tape augmentation protocols allowed full weight-bearing immediately post-operatively. Suture tape augmentation protocols generally allowed rehabilitation to occur on a quicker time-line with full weight-bearing by week 4-6 in 100% (3/3) of protocols and full ROM by week 8-10 in 66% (2/3) protocols. RTS was consistent in repair protocols (100% at week 12-16) but varied more in reconstruction. CONCLUSION: There is significant variability in the post-operative protocols after surgery for ankle instability. ROM was highly variable across protocols and did not always match-up with supporting literature for early mobilization of the ankle. Return to sport was most likely to correlate between protocols and the literature. Weight-bearing was consistent between most protocols but requires further research to determine the best practice. Overall, the variability between programs demonstrated the need for standardization of rehabilitation protocols.

Blood Flow Restriction Therapy: Where We Are and Where We Are Going.

Blood flow restriction therapy (BFRT) is an innovative training method for the development of muscle strength and hypertrophy in the athletic and clinical settings. Through the combination of venous occlusion and low-load resistance training, it induces muscle development through a number of proposed mechanisms including anaerobic metabolism, cellular swelling, and induction of type 2 muscle fibers. Muscle weakness and atrophy are prevalent among musculoskeletal rehabilitation patients, causing delayed return to functional activity. In traditional resistance training, muscle development requires exercise loads of 70% of one-repetition maximum (1RM), but the stress placed on connective tissues and joints can be detrimental to the elderly and rehabilitation patients. However, BFRT with loads of 20% to 40% of 1RM has been shown consistently in the literature to increase muscle strength, hypertrophy, and angiogenesis. The rate of adverse effects has not been found to be greater than that in traditional high-load resistance training, but its effects on the cardiovascular system have yet to be evaluated in long-term studies. Although further investigations are needed to determine the exact mechanism and optimal usage, current evidence is promising for the application of BFRT in athletes, rehabilitation patients, and the elderly patients.

Initial Response of Mature, Experienced Runners to Barefoot Running: Transition to Forefoot Strike.

INTRODUCTION: Forefoot strike has been advocated for many runners because of the relatively lower impact and push-off forces compared to a heel strike. The purpose of this study was to explore the ability of mature (> 30 years old), experienced runners to transition from a heel foot strike to a forefoot strike when first introduced to barefoot running on a treadmill. We hypothesized: 1) mature runners who heel strike while wearing traditional training shoes would persist in heel striking immediately following a switch to barefoot, 2) mean shoe heel-to-toe drop would be significantly greater in runners who persist in heel striking when running barefoot compared to those who transition to a forefoot strike pattern, and 3) there would be a significant decrease in heel striking in the barefoot condition as running speeds increased. METHODS: This was a controlled crossover laboratory study. Thirty-three experienced runners (average 23.4 miles per week) with an average age of 45.6 years were recruited for this study. The participants first ran in their standard running shoes and subsequently barefoot. A motion capture system was utilized to detect and analyze any transition from heel strike to forefoot strike made by study participants. RESULTS: Of the 26 participants who were classified as heel strike runners in their running shoes, 50% (13/26, p = 0.001) transitioned to forefoot strike when changing from running in shoes to running barefoot. CONCLUSIONS: The injuries associated with transition from standard running shoes to barefoot running or minimalist shoes may be influenced by the persistence of heel striking in mature runners. Older experienced runners may have limited ability to transition from heel to forefoot striking when first introduced to barefoot running. Mature runners should be cautious when beginning a minimalist shoe or barefoot running regimen.

Barefoot Running: The Effects of an 8-Week Barefoot Training Program.

BACKGROUND: It has been proposed that running barefoot can lead to improved strength and proprioception. However, the duration that a runner must train barefoot to observe these changes is unknown. HYPOTHESIS: Runners participating in a barefoot running program will have improved proprioception, increased lower extremity strength, and an increase in the volume or size of the intrinsic musculature of the feet. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: In this 8-week study, 29 runners with a mean age of 36.34 years were randomized into either a control group (n = 10) who completed training in their regular running shoes or to an experimental barefoot group (n = 14). Pretraining tests consisted of a volumetric measurement of the foot followed by a strength and dynamic balance assessment. Five subjects completed the pretests but did not complete the study for reasons not related to study outcomes. Participants then completed 8 weeks of training runs. They repeated the strength and dynamic balance assessment after 8 weeks. RESULTS: Significant changes from baseline to 8 weeks were observed within the barefoot group for single-leg hop (right, P = .0121; left, P = .0430) and reach and balance (right, P = .0029) and within the control group for single-left leg hop (P = .0286) and reach and balance (right, P = .0096; left, P = .0014). However, when comparing the differences in changes from baseline to 8 weeks between the barefoot and control groups, the improvements were not significant at the .05 level for all measures. CONCLUSION: Although statistically significant changes were not observed between the pre- and posttest evaluations in strength and proprioception with the 8-week low-intensity barefoot running regimen, this does not necessarily mean that these changes do not occur. It is possible that it may take months or years to observe these changes, and a short course such as this trial is insufficient.