Anterior Cruciate Ligament Return to Sport after Injury Scale (ACL-RSI) Scores over Time After Anterior Cruciate Ligament Reconstruction: A Systematic Review with Meta-analysis.

BACKGROUND: Psychological readiness is an important consideration for athletes and clinicians when making return to sport decisions following anterior cruciate ligament reconstruction (ACLR). To improve our understanding of the extent of deficits in psychological readiness, a systematic review is necessary. OBJECTIVE: To investigate psychological readiness (measured via the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI)) over time after ACL tear and understand if time between injury and surgery, age, and sex are associated with ACL-RSI scores. METHODS: Seven databases were searched from the earliest date available to March 22, 2022. Articles reporting ACL-RSI scores after ACL tear were included. Risk of bias was assessed using the ROBINS-I, RoB-2, and RoBANS tools based on the study design. Evidence certainty was assessed for each analysis. Random-effects meta-analyses pooled ACL-RSI scores, stratified by time post-injury and based on treatment approach (i.e., early ACLR, delayed ACLR, and unclear approach). RESULTS: A total of 83 studies were included in this review (78% high risk of bias). Evidence certainty was 'weak' or 'limited' for all analyses. Overall, ACL-RSI scores were higher at 3 to 6 months post-ACLR (mean = 61.5 [95% confidence interval (CI) 58.6, 64.4], I2 = 94%) compared to pre-ACLR (mean = 44.4 [95% CI 38.2, 50.7], I2 = 98%), remained relatively stable, until they reached the highest point 2 to 5 years after ACLR (mean = 70.7 [95% CI 63.0, 78.5], I2 = 98%). Meta-regression suggests shorter time from injury to surgery, male sex, and older age were associated with higher ACL-RSI scores only 3 to 6 months post-ACLR (heterogeneity explained R2 = 47.6%), and this reduced 1-2 years after ACLR (heterogeneity explained R2 = 27.0%). CONCLUSION: Psychological readiness to return to sport appears to improve early after ACL injury, with little subsequent improvement until ≥ 2-years after ACLR. Longer time from injury to surgery, female sex and older age might be negatively related to ACL-RSI scores 12-24 months after ACLR. Due to the weak evidence quality rating and the considerable importance of psychological readiness for long-term outcomes after ACL injury, there is an urgent need for well-designed studies that maximize internal validity and identify additional prognostic factors for psychological readiness at times critical for return to sport decisions. REGISTRATION: Open Science Framework (OSF), https://osf.io/2tezs/ .

High prevalence of associated injuries in anterior cruciate ligament tears: A detailed magnetic resonance imaging analysis of 254 patients.

OBJECTIVES: To evaluate the type and prevalence of associated injuries by using magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS: Data from the Natural Corollaries and Recovery after ACL injury multicenter longitudinal cohort study were analyzed. Between May 2016 and October 2018, patients aged between 15 and 40 years, who had experienced an ACL tear within the last 6 weeks and sought medical attention at one of seven healthcare clinics in Sweden, were invited to participate. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopedic knee surgeon and a musculoskeletal radiologist reviewed all the MRI scans. The following structures were assessed: posterior cruciate ligament (PCL), medial collateral ligament (MCL) complex, lateral collateral ligament (LCL), popliteus tendon, medial meniscus (MM), lateral meniscus (LM), and cartilage. In addition, the presence of bone bruising, impaction fractures in the lateral femoral condyle (LFC) or posterolateral tibia (PLT), and Segond fractures were also assessed.  RESULTS: A total of 254 patients (48.4% males) with a mean age of 25.4 ± 7.1 years were included. The prevalence of associated injuries was as follows: PCL (0.4%), MCL {41.3% [superficial MCL and deep MCL (dMCL) 16.5%; isolated dMCL 24.8%]}, LCL (2.4%), MM (57.4%), LM (25.2%), cartilage (15.0%), bone bruising (92.9%), impaction fracture in the LFC (45.7%) and PLT (4.7%), and Segond fracture (7.5%). CONCLUSIONS: The prevalence of associated injuries in patients with ACL tears was high. The findings reported in this study may serve as a reference tool for orthopedic surgeons and radiologists in the diagnosis of associated injuries using MRI in patients with ACL tears.

Knee-Related Quality of Life Compared Between 20 and 35 Years After an Anterior Cruciate Ligament Injury Treated Surgically With Primary Repair or Reconstruction, or Nonsurgically.

BACKGROUND: Quality of life (QoL) is affected up to 5 years after an anterior cruciate ligament (ACL) injury. Knee impairment and osteoarthritis (OA) development increase over time, and this may affect QoL at a long-term follow-up. PURPOSE: To investigate changes in health- and knee-related QoL between 20 and 35 years after ACL injury and compare it between patients treated with or without ACL surgery, as well as to study how symptomatic OA (SOA) is associated with change in QoL. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Between 1980 and 1983, 139 patients with acute ACL rupture were allocated to surgical or nonsurgical treatment of the ACL. Both groups completed a structured rehabilitation program. Of those patients, 59 were followed for 20 and 35 years after ACL rupture. After 10 crossovers, 33 patients were treated with primary repair or ACL reconstruction, and 26 were treated without ACL surgery. Combined radiographic OA and knee symptoms at 35 years was defined as SOA. QoL was assessed at 20 and 35 years after injury with the Knee injury and Osteoarthritis Outcome Score QoL (KOOS-QoL) subscale (range, 1-100), ACL-QoL questionnaire (total score and 5 subscales; range, 1-100), European QoL-5 Dimensions Questionnaire, and visual analog scale. Results were analyzed with paired and independent-sample t tests and chi-square tests. RESULTS: Knee-related QoL was impaired at both 20 and 35 years after ACL injury, and differences were dependent on the measurement outcome. In the total cohort, KOOS-QoL did not change but both total ACL-QoL score (7.1 points; 95% CI, 2.2-11.9) and 4 of 5 subscales (5-10 points) decreased (P < .05). No differences were found between treatment groups. QoL decreased overall in patients with SOA, with a 21-point difference within-group change in KOOS-QoL (SOA or non-SOA) between 20 and 35 years of follow-up (P = .001; Cohen d = 1.0). CONCLUSION: An ACL injury impairs knee-related QoL for up to 35 years, with no difference between treatment approaches (initial repair or later reconstruction compared with nonsurgical treatment). The deterioration decreases with longer follow-up. Clinicians should be aware of differences in QoL depending on the measurement outcome.

High Prevalence of Superficial and Deep Medial Collateral Ligament Injuries on Magnetic Resonance Imaging in Patients With Anterior Cruciate Ligament Tears.

PURPOSE: To assess the prevalence of and factors associated with medial collateral ligament (MCL) complex injuries on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) tears. METHODS: Data were extracted from the Natural Corollaries and Recovery After ACL Injury (NACOX) multicenter longitudinal cohort study. Between May 2016 and October 2018, patients who presented to 1 of 7 health care clinics across Sweden with an ACL tear sustained no more than 6 weeks earlier and who were aged between 15 and 40 years at the time of injury were invited to participate. All the patients included in this study underwent MRI. The mean time from injury to MRI was 19.6 ± 15.2 days. An orthopaedic surgeon specializing in knee surgery and a musculoskeletal radiologist reviewed all MRI scans. Injuries to the superficial MCL (sMCL), deep MCL (dMCL), and posterior oblique ligament were identified. Stepwise forward multiple binary logistic regression analyses were used to evaluate patient characteristics (age, sex, body mass index, preinjury Tegner activity level, and activity at injury) and injuries on MRI (lateral meniscus [LM] injury, medial meniscus [MM] injury, pivot shift-type bone bruising, medial femoral condyle [MFC] bone bruising, and lateral femoral condyle [LFC] impaction) associated with the presence of MCL complex tears. RESULTS: In total, 254 patients (48.4% male patients) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries was 16.5% (42 of 254) and 24.8% (63 of 254), respectively. No isolated sMCL injuries were found. Posterior oblique ligament injuries were found in 12 patients (4.7%) with MCL (sMCL and dMCL) injuries. An LM injury (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.73-8.94; P = .001) and LFC impaction (OR, 2.37; 95% CI, 1.11-5.07; P = .02) increased the odds of having an MCL injury, whereas an MM injury (OR, 0.26; 95% CI, 0.12-0.59; P = .001) reduced the odds. Isolated dMCL injuries were significantly associated with MFC bone bruising (OR, 4.21; 95% CI, 1.92-9.25; P < .001) and LFC impaction (OR, 3.86; 95% CI, 1.99-7.49; P < .001). CONCLUSIONS: The overall combined prevalence of MCL (sMCL and dMCL) injuries and isolated dMCL injuries in patients with ACL tears was high (16.5% + 24.8% = 41.3%). The presence of an LM injury and LFC impaction increased the odds of having an MCL injury, whereas the presence of an MM injury reduced the odds. MFC bone bruising and LFC impaction were associated with the presence of isolated dMCL injuries. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

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.

Accelerometer-assessed physical activity patterns during the first two years after a non-surgically treated ACL injury.

OBJECTIVES: To describe physical activity patterns and analyze changes during the first two years after a non-surgically treated ACL injury, and to assess correlations between accelerometer-assessed physical activity and self-reported knee function and knee-related quality of life. DESIGN: Prospective cohort study. PARTICIPANTS: 128 patients (61 females, 25.2 ± 7.1 years) with acute ACL injury. MAIN OUTCOME MEASURES: Physical activity patterns were measured with accelerometry. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form, and knee-related quality of life was assessed using the Anterior Cruciate Ligament Quality of Life questionnaire. RESULTS: Moderate to vigorous physical activity (MVPA) and steps per day increased from baseline to 3 months (p < .001), with no further increase from 3 to 24 months (p > .05). Time in MVPA did not correlate to patient-reported outcome measures at 3, 6, 12, or 24 months (p > .05). CONCLUSIONS: Physical activity increased from acute phase to 3 months after non-surgically treated ACL injury, but almost one in four patients did not reach recommended levels of physical activity. Physical activity did not correlate with knee function or quality of life. Patients may need improved support to return to physical activity after ACL injury. LEVEL OF EVIDENCE: Level II. TRIAL REGISTRATION: NCT02931084.

Athletes' experiences of using a self-directed psychological support, the BAck iN the Game (BANG) smartphone application, during rehabilitation for return to sports following anterior cruciate ligament reconstruction.

BACKGROUND: Following anterior cruciate ligament reconstruction (ACLR), many athletes do not return to their sport, often driven by concerns about re-injury. Psychological support strategies might help, but are not routinely included in rehabilitation after ACLR. The BAck iN the Game (BANG) intervention is a 24-week eHealth program delivered via smartphone application (app), beginning directly after ACLR, with a self-directed approach that aims to target the specific challenges athletes encounter in rehabilitation. AIM: To describe athletes' experiences of using the BANG app during rehabilitation, to support returning to sport following ACLR. METHOD: Participants were athletes, in contact and/or non-contact pivoting sports, who had ACLR with the goal to return to sports. Semi-structured, individual interviews were conducted 6-10 months after their ACLR; all had access to the BANG intervention. Verbatim transcripts were analysed with a qualitative content analysis. RESULTS: The 19 participants were 17-30 years, mean 21.6 years (SD 3.5); 7 men and 12 women. The analysis generated three main categories. (A) Interacting with the app illustrated how, when, or why the participants engaged with the app. The app was helpful because of its varying content, the notifications served as reminders and participants stopped using the app when no longer needing it. (B) Challenging experiences with the app illustrated that the app itself came with some difficulties e.g., content not appearing with the right timing and material not tailored to their sport. (C) Supportive experiences with the app reflected how the app facilitated the participants' rehabilitation progress; it included positive aspects of the app content and navigation, boosting their confidence to return to sport, and motivated them to continue with rehabilitation. CONCLUSION: The analysis of the interviews illustrates athletes' awareness in interacting with, and the challenging and supportive experiences of using the app. The BANG app might provide support for returning to sport, primarily psychological support, as an adjunct to regular physiotherapy-guided rehabilitation. Athletes' experiences of the BANG app could be improved by healthcare professionals providing additional advice about when to use which content and why. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03959215. Registered 22 May 2019.

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.

What Factors Identified in Initial Osteoarthritis Management Are Associated With Poor Patient-reported Outcomes After THA? A Register-based Study.

BACKGROUND: Some patients report long-term pain or no improvement in health-related quality of life (HRQoL) or are dissatisfied after THA. However, factors associated with these poorer patient-reported outcomes after surgery are inconsistent and have typically been studied in the late phase of hip osteoarthritis (OA) among patients already eligible for surgery. Earlier identification of risk factors would provide time to address modifiable factors, helping to improve patients' pain, HRQoL, and satisfaction after surgery and reduce the burden on orthopaedic clinics by referring patients who are better prepared for surgery. QUESTIONS/PURPOSES: We analyzed data from patients with hip OA referred to a first-line OA intervention program in primary healthcare at a stage when they had not been referred for THA, and asked: (1) What percentage of patients who proceed to THA report lack of improvement in pain, lack of improvement in HRQoL as measured by the EQ-5D, or are not satisfied with surgery 1 year after THA? (2) What associations exist between baseline factors at referral to this first-line OA intervention program and these poorer patient-reported outcomes 1 year after THA? METHODS: We included 3411 patients with hip OA (mean age 67 ± 9 years, 63% [2160 of 3411] women) who had been referred for first-line OA interventions between 2008 and 2015 and subsequently underwent THA for OA. All patients were initially identified through the Swedish Osteoarthritis Register, which follows and evaluates patients in a standardized national first-line OA intervention program. Then, we identified those who were also registered in the Swedish Arthroplasty Register with a THA during the study period. We included only those with complete patient-reported outcome measures for pain, HRQoL, and satisfaction preoperatively and 1-year postoperatively, representing 78% (3411 of 4368) of patients, who had the same baseline characteristics as nonrespondents. Multiple logistic regression was used to assess the associations between 14 baseline factors and the aforementioned patient-reported outcomes of pain, HRQoL, and satisfaction 1 year after THA, adjusted for all included factors. RESULTS: Five percent (156 of 3411) of the study population lacked improvement in pain, 11% (385 of 3411) reported no improvement in HRQoL, and 10% (339 of 3411) reported they were not satisfied with surgery 1 year after THA. Charnley Class C (multiple-joint OA or another condition that affects the ability to walk) was associated with all outcomes: lack of improvement in pain (OR 1.84 [95% CI 1.24 to 2.71]; p = 0.002), lack of improvement in HRQoL (OR 1.83 [95% CI 1.42 to 2.36]; p < 0.001), and not being satisfied (OR 1.40 [95% CI 1.07 to 1.82]; p = 0.01). Older age was associated with a lack of improvement in pain (OR per year 1.03 [95% CI 1.01 to 1.05]; p = 0.02), lack of improvement in HRQoL (OR per year 1.04 [95% CI 1.03 to 1.06]; p < 0.001), and not being satisfied (OR per year 1.03 [95% CI 1.01 to 1.05]; p < 0.001). Depression was associated with a lack of improvement in pain (OR 1.54 [95% CI 1.00 to 2.35]; p = 0.050) and with not being satisfied (OR 1.50 [95% CI 1.11 to 2.04]; p = 0.01) but not with a lack of improvement in HRQoL (OR 1.04 [95% CI 0.76 to 1.43]; p = 0.79). Having four or more comorbidities was associated with a lack of improvement in HRQoL (OR 2.08 [95% CI 1.39 to 3.10]; p < 0.001) but not with a lack of improvement in pain and not being satisfied. CONCLUSION: The results of this study showed that older age, Charley Class C, and depression in patients with first-line OA interventions were risk factors associated with poorer outcomes regarding pain, HRQoL, and satisfaction after THA. Screening patients with hip OA for depression early in the disease course would provide increased time to optimize treatments and may contribute to better patient-reported pain, HRQoL, and satisfaction after future THA. Further research should focus on identifying the optimal time for surgery in patients with depression, as well as what targeted interventions for depression can improve outcome of surgery in these patients. LEVEL OF EVIDENCE: Level III, therapeutic study.

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.

Perspectives on health care and self-management of osteoarthritis among patients who desire surgery: A qualitative interview study.

BACKGROUND: Expressing a desire for surgery before participating in first-line osteoarthritis (OA) interventions (patient education and exercise therapy) has been shown to contribute to poorer outcomes from the interventions, but we lack knowledge on how these patients reflect on health care and self-management of OA. OBJECTIVES: To explore and describe patients' perspectives of health care and self-management of OA among those expressing a desire for surgery before participating in first-line OA interventions. METHODS: Sixteen patients with hip or knee OA referred to participate in a standardized first-line OA intervention program in primary health care in Sweden were included in the study. We used individual semi-structured interviews to collect data, which were analyzed using inductive qualitative content analysis. RESULTS: One theme of meaning "A multifaceted picture of needs, expectations, and individual choices" and five categories were identified as perspectives from the participants regarding health care and self-management of OA: 1) lacking control and needing support; 2) standing alone in an unsupportive environment; 3) going with the flow; 4) having expectations; and 5) taking ownership. CONCLUSION: Patients who express a desire for surgery before participating in first-line interventions for OA are not a homogeneous group. They describe a broad range of perspectives on how they reason and reflect on health care and self-management of OA based on their own needs, expectations, and choices. Findings from this study strengthen insights on the importance of exploring the patient's perspectives and individualizing OA interventions to achieve the lifestyle changes that first-line interventions strive to accomplish.

The experience and influence of fear after anterior cruciate ligament reconstruction: an interview study with young athletes.

BACKGROUND: Despite good physical function, many athletes do not return to sports after an anterior cruciate ligament reconstruction (ACLR). One important reason for this is fear of new injury. The aim of this study was to investigate young athletes' experiences of knee-related fear after an ACLR and how they perceive this fear to affect them in their sporting and everyday life. METHODS: A qualitative interview study was conducted, using semi-structured interviews. Athletes who were active in contact or pivoting sport before an ACL injury, with the goal of returning to the same sport and who scored highly on fear of new injury at six months post-ACLR, were asked to participate. Ten athletes (six women and four men, aged 17-25 years), were interviewed by an independent researcher, 7-9 months after ACLR. Content analysis employing an abductive approach was used. RESULTS: The analysis resulted in three categories with associated subcategories: 1. The expressions of fear; (i) reason for fear, (ii) changes in fear over time, and (iii) injury situation. 2. Reactions, consequences, and adaptations; (i) reactions, (ii) behavioural adaptation and influence on rehabilitation and daily life, (iii) present consequences, and (iv) consequences for the future. 3. Fear and adaptations related to returning to sports; (i) fear related to returning to sports and, (ii) adaptations in sports and life due to fear. Fear was described in broad and complex ways, with fear of a new injury being expressed as one of several aspects. Various reasons (e.g., seeing others getting injured in the past, previous experience of injury, failed rehabilitation, perceived knee instability) were given to explain the fear, and athletes reacted both physically and mentally to fear. Both positive and negative adaptations to fear were described, in both daily life and sports. CONCLUSION: The results contribute to an increased understanding of fear as an essential psychological factor to consider during rehabilitation and leaves the way open for research to investigate how physiotherapists can work to manage fear better among ACLR patients.

The Swedish version of the Anterior Cruciate Ligament Quality Of Life measure (ACL-QOL): translation and measurement properties.

PURPOSE: To translate the ACL-QOL from English to Swedish and evaluate measurement properties for use after surgical and non-surgical management of anterior cruciate ligament (ACL) injury. METHODS: The ACL-QOL was translated from English to Swedish and data were pooled from 13 cohorts to enable a comprehensive evaluation of measurement properties in line with COSMIN guidelines. We evaluated internal consistency, test-re-test reliability, measurement error, structural validity [confirmatory factor analysis (CFA)], construct validity and responsiveness (hypothesis testing), and floor/ceiling effects. Results were stratified by time since injury (≤ 1.5 years; 2-10 years, 15-25 years; > 30 years) and ACL management strategy [surgical (n = 1163), non-surgical (n = 570)]. RESULTS: The Swedish ACL-QOL had sufficient internal consistency (total and domain scores) for use in surgically managed (Cronbach's alpha ≥ 0.744) and non-surgically managed (≥ 0.770) ACL-injured individuals at all time-points. Test-re-test reliability was sufficient [intraclass correlation coefficients: all domains > 0.80, total score 0.93 (95% CI 0.86-0.96)]. The standard error of measurement was 5.6 for the total score and ranged from 7.0 to 10.3 for each domain. CFA indicated sufficient SRMR values when using the total score or five domains; however, CFI and RMSEA values did not meet cut-offs for good model fit. Hypothesis testing indicated sufficient construct validity and responsiveness. Floor effects were negligible and ceiling effects were negligible or minor. CONCLUSION: The Swedish version of the ACL-QOL has sufficient internal consistency, test-re-test reliability, construct validity and responsiveness, for use in people with ACL injury managed with or without ACL surgery. Model fit could be improved and investigation into the source of misfit is warranted.

Biopsychosocial Factors Associated With Return to Preinjury Sport After ACL Injury Treated Without Reconstruction: NACOX Cohort Study 12-Month Follow-up.

BACKGROUND: The limited research on prognosis after nonsurgical management of anterior cruciate ligament (ACL) injury has focused on physical factors. We aimed to assess relationships between key patient-reported outcomes, in line with a biopsychosocial approach, and returning to preinjury sport at 12 months after ACL injury treated without reconstruction. HYPOTHESIS: We hypothesized that biopsychosocial factors would be associated with returning to preinjury sport at 12 months after ACL injury. STUDY DESIGN: Prospective single cohort study. LEVEL OF EVIDENCE: Level 2. METHODS: Patients who had an ACL injury and did not have reconstruction during the first year after injury were recruited from healthcare clinics in Sweden, and followed up at 3, 6, and 12 months after injury. Return to preinjury sport at 12 months was the primary outcome. Explanatory variables were psychological readiness to return to sport, knee-related quality of life, and self-reported knee function. Using generalized estimating equations, we evaluated the relationships between the explanatory variables and the primary outcome at each timepoint. RESULTS: Data were analyzed for 88 participants with a median age of 27 years (15-40 years). Soccer was the most frequently reported preinjury sport (n = 22). Forty participants (46%) had returned to their preinjury sport at 12 months after ACL injury. The odds of returning to preinjury sport at 12 months increased with higher self-reported knee function at 6 months (odds ratio [OR], 1.1; 95% CI, 1.0-1.1), and the odds of being returned to the preinjury sport at 12 months doubled for every 1-point increase (1-10 scale) in psychological readiness to return to sport measured at 12 months (OR, 1.9; 95% CI, 1.2-3.2). CONCLUSION: Superior self-reported knee function at 6 months and greater psychological readiness to return to sport at 12 months were associated with returning to the preinjury sport 1 year after ACL injury treated without reconstruction. CLINICAL RELEVANCE: Consider highlighting the relevance of biopsychosocial factors to returning to preinjury sport after ACL injury when discussing prognosis during shared decision-making.

High prevalence of meniscal ramp lesions in anterior cruciate ligament injuries.

PURPOSE: To evaluate the prevalence of and factors associated with meniscal ramp lesions on magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) injuries. METHODS: Data from the Natural Corollaries and Recovery after ACL injury multicentre longitudinal cohort study (NACOX) were analysed. Only patients who underwent MRI were included in this study. All MRI scans were reviewed by an orthopaedic knee surgeon and a musculoskeletal radiologist. The patients were divided into two groups, those with and without ramp lesions according to MRI findings. Univariable and stepwise forward multiple logistic regression analyses were used to evaluate patient characteristics (age, gender, body mass index, pre-injury Tegner activity level, activity at injury) and concomitant injuries on MRI (lateral meniscus, medial collateral ligament [MCL], isolated deep MCL, lateral collateral ligament, pivot-shift-type bone bruising, posteromedial tibial [PMT] bone bruising, medial femoral condyle bone bruising, lateral femoral condyle [LFC] impaction and a Segond fracture) associated with the presence of meniscal ramp lesions. RESULTS: A total of 253 patients (52.2% males) with a mean age of 25.4 ± 7.1 years were included. The overall prevalence of meniscal ramp lesions was 39.5% (100/253). Univariate analyses showed that contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising, LFC impaction and the presence of a Segond fracture increased the odds of having a meniscal ramp lesion. Stepwise forward multiple logistic regression analysis revealed that the presence of a meniscal ramp lesion was associated with contact sports at ACL injury [odds ratio (OR) 2.50; 95% confidence intervals (CI) 1.32-4.72; P = 0.005], pivot-shift-type bone bruising (OR 1.29; 95% CI 1.01-1.67; P = 0.04), PMT bone bruising (OR 4.62; 95% CI 2.61-8.19; P < 0.001) and the presence of a Segond fracture (OR 4.38; 95% CI 1.40-13.68; P = 0.001). CONCLUSION: The overall prevalence of meniscal ramp lesions in patients with ACL injuries was high (39.5%). Contact sports at ACL injury, pivot-shift-type bone bruising, PMT bone bruising and the presence of a Segond fracture on MRI were associated with meniscal ramp lesions. Given their high prevalence, meniscal ramp lesions should be systematically searched for on MRI in patients with ACL injuries. Knowledge of the factors associated with meniscal ramp lesions may facilitate their diagnosis, raising surgeons' and radiologists' suspicion of these tears. LEVEL OF EVIDENCE: III.

Bilateral changes in knee joint laxity during the first year after non-surgically treated anterior cruciate ligament injury.

OBJECTIVES: Analyse changes in knee laxity between 3, 6, 12 and 24 months after non-surgically treated ACL injury and to analyse associations between knee laxity and knee function, self-reported knee stability, ACL-Return to Sport after Injury (ACL-RSI), fear and confidence at different timepoints during recovery. DESIGN: Prospective cohort study. PARTICIPANTS: 125 patients (67 males, mean age 25.0 ± 7.0 years) with acute ACL injury. MAIN OUTCOME: Laxity was measured using KT-1000 arthrometer. Self-reported knee function was assessed using the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF). Confidence and fear were assessed with questions from the ACL-RSI scale. Subjectively knee stability was assessed using SANE. RESULTS: Knee laxity increased bilaterally from 3 to 12 months, and in the non-involved knee from 3 to 24 months (p˂0.05), although mean change was below 1 mm. Side-to-side difference in knee laxity was correlated with IKDC-SKF (r = -0.283) and knee stability in rehabilitation/sport activities (r = -0.315) at 6 months, but not with confidence/fear. CONCLUSION: Knee laxity increased bilaterally during the first year after non-surgically treated ACL injury, though, the mean change in knee laxity was below 1 mm and the clinical significance is unknown. Knee laxity was weakly associated with knee function and perceived knee stability. LEVEL OF EVIDENCE: Level II TRIAL REGISTRATION: NCT02931084.

Learning from the past to plan for the future: A scoping review of musculoskeletal clinical research in Sweden 2010-2020.

Background: The aims of this study are to 1) determine the scope of musculoskeletal (MSK)-related clinical research in Sweden; 2) collate the amount of first-tier funding received; 3) discuss strategies and infrastructure supporting future MSK clinical trials in Sweden. Methods: A systematic scoping review protocol was applied in PubMed, Scopus, and SweCRIS databases. The articles were examined, and data were extracted in multiple stages by three blinded authors. Results: The search strategy resulted in 3,025 publications from 479 Swedish-affiliated authors. Primary health care was the basis for 14% of the publications, 84% from secondary health care, and 2% from occupational health care with a similar proportional distribution of first-tier research grant financing. Approximately one in six publications were randomized controlled trials (RCTs), while the majority were of observational cohort design. The majority of publications in primary and occupational health care were related to pain disorders (51 and 67%, respectively), especially diagnosis, prognosis, and healthcare organizational-related interventions (34%) and rehabilitation (15%) with similar proportional distribution of first-tier research grant financing. In secondary health care, rheumatic inflammatory disorder-related publications were most prevalent (30%), most frequently concerning diagnosis, prognosis, and healthcare organizational-related interventions (20%), attracting approximately half of all first-tier funding. Publications related to degenerative joint disorders (25%), fractures (16%), and joint, tendon, and muscle injuries (13%) frequently concerned surgical and other orthopedic-related interventions (16, 6, and 8%, respectively). Pain disorder-related publications (10%) as well as bone health and osteoporosis-related publications (4%) most frequently concerned diagnosis, prognosis, and healthcare organizational-related interventions (5 and 3%, respectively). Conclusions: Swedish-affiliated MSK disorder research 2010-2020 was predominantly observational cohort rather than RCT based. There was skewed first-tier funding allocation considering prevalence/incidence and burden of disease. Use of infrastructure supporting register-based RCTs, placebo-controlled RCTs, and hybrid effectiveness-implementation studies on prevention and clinical intervention is important strategies for the future in all healthcare sectors.

A Psychological Support Intervention to Help Injured Athletes "Get Back in the Game": Design and Development Study.

BACKGROUND: After a serious knee injury, up to half of athletes do not return to competitive sport, despite recovering sufficient physical function. Athletes often desire psychological support for the return to sport, but rehabilitation clinicians feel ill-equipped to deliver adequate support. OBJECTIVE: We aimed to design and develop an internet-delivered psychological support program for athletes recovering from knee ligament surgery. METHODS: Our work for developing and designing the Back in the Game intervention was guided by a blend of theory-, evidence-, and target population-based strategies for developing complex interventions. We systematically searched for qualitative evidence related to athletes' experiences with, perspectives on, and needs for recovery and return to sport after anterior cruciate ligament (ACL) injury. Two reviewers coded and synthesized the results via thematic meta-synthesis. We systematically searched for randomized controlled trials reporting on psychological support interventions for improving ACL rehabilitation outcomes in athletes. One reviewer extracted the data, including effect estimates; a second reviewer checked the data for accuracy. The results were synthesized descriptively. We conducted feasibility testing in two phases-(1) technical assessment and (2) feasibility and usability testing. For phase 1, we recruited clinicians and people with lived experience of ACL injury. For phase 2, we recruited patients aged between 15 and 30 years who were within 8 weeks of ACL reconstruction surgery. Participants completed a 10-week version of the intervention and semistructured interviews for evaluating acceptability, demand, practicality, and integration. This project was approved by the Swedish Ethical Review Authority (approval number: 2018/45-31). RESULTS: The following three analytic themes emerged from the meta-synthesis (studies: n=16; participants: n=164): (1) tools or strategies for supporting rehabilitation progress, (2) barriers and facilitators for the physical readiness to return to sport, and (3) barriers and facilitators for the psychological readiness to return to sport. Coping strategies, relaxation, and goal setting may have a positive effect on rehabilitation outcomes after ACL reconstruction (randomized controlled trials: n=7; participants: n=430). There were no trials of psychological support interventions for improving the return to sport. Eleven people completed phase 1 of feasibility testing (technical assessment) and identified 4 types of software errors, which we fixed. Six participants completed the feasibility and usability testing phase. Their feedback suggested that the intervention was easy to access and addressed the needs of athletes who want to return to sport after ACL reconstruction. We refined the intervention to include more multimedia content and support access to and the use of the intervention features. CONCLUSIONS: The Back in the Game intervention is a 24-week, internet-delivered, self-guided program that comprises 7 modules that complement usual rehabilitation, changes focus as rehabilitation progresses, is easy to access and use, and includes different psychological support strategies.

Kinesiophobia, Knee Self-Efficacy, and Fear Avoidance Beliefs in People with ACL Injury: A Systematic Review and Meta-Analysis.

BACKGROUND: To improve the understanding of the psychological impacts of anterior cruciate ligament (ACL) injury, a systematic review synthesizing the evidence on knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury is needed. OBJECTIVE: The aim of this systematic review was to investigate knee self-efficacy, fear avoidance beliefs and kinesiophobia following ACL injury, and compare these outcomes following management with rehabilitation alone, early and delayed ACL reconstruction (ACLR). METHODS: Seven databases were searched from inception to April 14, 2022. Articles were included if they assessed Tampa Scale of Kinesiophobia (TSK), Knee Self-Efficacy Scale (KSES), or Fear Avoidance Beliefs Questionnaire (FABQ). Risk of bias (RoB) was assessed using domain-based RoB tools (ROBINS-1, RoB 2, RoBANS), and GRADE-assessed certainty of evidence. Random-effects meta-analyses pooled outcomes, stratified by time post-injury (pre-operative, 3-6 months, 7-12 months, > 1-2 years, > 2-5 years, > 5 years). RESULTS: Seventy-three studies (70% high RoB) were included (study outcomes: TSK: 55; KSES: 22; FABQ: 5). Meta-analysis demonstrated worse kinesiophobia and self-efficacy pre-operatively (pooled mean [95% CI], TSK-11: 23.8 [22.2-25.3]; KSES: 5.0 [4.4-5.5]) compared with 3-6 months following ACLR (TSK-11: 19.6 [18.7-20.6]; KSES: 19.6 [18.6-20.6]). Meta-analysis suggests similar kinesiophobia > 3-6 months following early ACLR (19.8 [4.9]) versus delayed ACLR (17.2 [5.0]). Only one study assessed outcomes comparing ACLR with rehabilitation only. CONCLUSIONS: Knee self-efficacy and kinesiophobia improved from pre-ACLR to 3-6 months following ACLR, with similar outcomes after 6 months. Since the overall evidence was weak, there is a need for high-quality observational and intervention studies focusing on psychological outcomes following ACL injury.