Early Weight-bearing Rehabilitation Protocol After Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament (ACL) injury is one of the common sports injuries. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment for ACL injury, aiming to regain normal anatomical structure and stability of the knee joint and promote the patient's return to sports. Under the guidance of the concept of enhanced recovery after surgery, early weight-bearing rehabilitation (EWB) is an important factor affecting patient function and quality of life. However, there is no consensus on whether EWB rehabilitation can be performed after ACL surgery. This study aims to explore the safety and feasibility of EWB after ACL surgery. The study implemented a gradual EWB rehabilitation program in the experimental group, including weight-shifting training, balance training, and gait training on the affected lower limb, and assessed wound healing and stability of the knee joint. The study found that EWB after ACLR is safe and feasible. EWB rehabilitation not only does not pose a negative effect on the patient's knee pain, swelling, wound healing, and stability, but also helps to improve knee active flexion and quality of life faster and better. The EWB program in this study is simple, safe, and effective, and it provides strong theoretical guidance and practical demonstration for accelerated rehabilitation after ACLR.

The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction.

PURPOSE: Patient-reported outcomes were compared between participants who followed the treatment algorithm of the Delaware-Oslo ACL Cohort, consisting of progressive preoperative and postoperative rehabilitation, patient education, clinical testing and shared decision-making about treatment choice, and those who followed usual care 9-12 years after anterior cruciate ligament reconstruction (ACLR). METHODS: Participants with primary ACLR were included from the Norwegian arm of the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry (usual care). The Knee Injury and Osteoarthritis Outcome Score (KOOS) subscale scores and the International Knee Documentation Committee-Subjective Knee Form (IKDC-SKF) scores were compared. KOOS scores for the usual care group were converted to IKDC-SKF scores with recently published validated crosswalk. The percentages of participants with scores above predefined thresholds for patient acceptable symptom state (PASS) were also calculated. RESULTS: Eighty of 100 (80%) participants from the Delaware-Oslo ACL Cohort and 1588 of 3248 (49%) from the usual care group participated in the follow-up. Participants from the Delaware-Oslo ACL Cohort had higher KOOS subscale (p < 0.001) and IKDC-SKF scores (p < 0.001), and a higher percentage reached PASS (84%-96% vs. 62%-76%, p ≤ 0.002) for KOOS Pain, symptoms, activities of daily living and sports compared to the usual care group. No significant differences were found for KOOS quality of life scores (not significant [n.s.]) or PASS percentages (80% vs. 74%, n.s.). CONCLUSION: Participants with ACLR who followed the Delaware-Oslo ACL Cohort treatment algorithm had reduced knee symptoms, superior function and higher percentages of satisfactory outcomes than participants who followed usual care. LEVEL OF EVIDENCE: Level II.

Use of electromyographic biofeedback in rehabilitation following anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

BACKGROUND: Rehabilitation following anterior cruciate ligament (ACL) reconstruction surgery is essential to regain functionality and return to previous activity level. Electromyographic biofeedback may be an effective intervention for rehabilitation of patients following ACL surgery. OBJECTIVE: To synthesize the available evidence on the effect of electromyographic biofeedback in the treatment of quadriceps strength following ACL surgery. DESIGN: Systematic review with meta-analysis. DATA SOURCES: PubMed, EMBASE, CENTRAL and Epistemonikos were searched. ELIGIBILITY CRITERIA: Randomized clinical trials with patients undergoing ACL reconstruction surgery comparing biofeedback with a standard rehabilitation control group. DATA EXTRACTION AND DATA SYNTHESIS: Two authors selected articles and performed data extraction. The analysed outcomes were strength, function, pain, knee extension and balance. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias Tool. Results were combined through random-effects meta-analysis, reporting mean differences. RESULTS: Eight articles were included in the qualitative analysis, and four articles were included in the quantitative analysis. The interventions lasted between 4 and 12 weeks. Three studies evaluated the effect of biofeedback on quadriceps strength; of these, two studies showed a significant difference in favour of the biofeedback group. In addition, biofeedback was found to improve knee extension [standardized mean difference - 1.3, 95% confidence interval (CI) - 1.74 to -0.86] and balance (one study). There was no significant difference in Lysholm score (mean difference -6.21, 95% CI -17.51 to 5.08; I2 =59%) or pain between the biofeedback group and the control group. CONCLUSION: Electromyographic biofeedback in knee rehabilitation could be useful following ACL reconstruction surgery. KEY MESSAGES: SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020193768).

The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction.

OBJECTIVE: To rate athletes' functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. METHODS: In our prospective multicenter cohort study, 88 (42 females) adults aged 18-35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. RESULTS: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be "over-cut-off-performers." CONCLUSIONS: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.

Use of blood flow restriction for increasing the strength of the ischiocrural muscles in anterior cruciate ligament rehabilitation: A case report.

BACKGROUND: The hamstring muscles have a key function in the stability of the knee, limiting the anterior translation of the tibia. Therefore, to better perform rehabilitation after anterior cruciate ligament (ACL) surgery, it is important to develop a specific program based on hamstring strength recovery. It is possible to increase strength and muscle hypertrophy through high load exercises (HL); the recommended load is about 60%-80% of a maximum repetition (MR). Although low-load resistance training (LL) is ineffective at reproducing these values, the use of Blood Flow Restriction (BFR) with LL exercises appears to allow athletes to increase strength and muscle hypertrophy. This could limit functional decline and mitigate muscle atrophy allowing to optimize the recovery path and load management in post-operative patients. Recent scientific evidence, as far as the increasingly frequent use of BFR in rehabilitation and sports rehabilitation is concerned, suggests that these devices could represent one of the most significant innovations in the physiotherapy field. The aim of this study was to increase the strength of the hamstrings in the early phases of ACL rehabilitation with an LL-BFR training protocol for speeding up the development of adequate muscle strength. CASE DESCRIPTIONS: The patient, a 25-year-old male professional footballer, suffered from ACL injury during a football match, and after three months, he underwent a reconstruction ACL surgery with medial Hamstring tendon autograft. The athlete engaged a pre-operative program to restore a full active and passive knee range of motion and increase muscular strength. The first rehabilitation phase was supported by the adoption of BFR for hamstring strengthening, starting from the sixth week post-surgery (T0). A complete assessment of posterior hamstring muscles was performed through a hand-held dynamometer and load detection platforms. Three different types of exercises, focusing on the hamstring muscles, were chosen. Two further assessments were performed over time (T1 ant T2), highlighting different changes that occurred. RESULTS: Interesting results showed a significant increase between T0 and T1 for all the assessed outcomes; in this case an average increase in strength of 59.87% between the beginning and the end of 4 weeks rehabilitation protocol was obtained in the first interval (T0-T1), while only 25.26% resulted in the second interval (T1-T2). However, the collected data should be considered with caution due to some limitations: the single experience of a single patient can hardly be generalized. Moreover, the reliance on isometric measurement of maximal strength and the absence of a direct strength measurement of the hamstrings during squat remain questionable. CONCLUSION: The final results suggest the capacity of the LL-BFR exercises to recreate a condition of a high intensity muscular effort with respect to load management, especially after surgery. This highlights the need to further investigate BFR adoption as it allows the patients to speed up their rehabilitation goals in developing adequate muscle strength.

Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport.

OBJECTIVES: To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports physiotherapy or deep clinical experience and those without such experience. DESIGN: Cross-sectional survey. SETTING: Online survey platform. PARTICIPANTS: Swiss physiotherapists. MAIN OUTCOME MEASURES: The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers. RESULTS: A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system. CONCLUSION: This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary.

Asymmetric loading strategies during squats following anterior cruciate ligament reconstruction: A longitudinal investigation with curve analyses throughout and after rehabilitation.

Investigations of kinetic asymmetries during bilateral squats following anterior cruciate ligament reconstruction (ACLR) are limited to mainly cross-sectional studies and discrete value data extracted at specific knee angles. We assessed loading asymmetries during squats longitudinally throughout rehabilitation using curve analysis and compared patient-reported outcome measures (PROMs) between those with and without asymmetry. Bodyweight squats were performed by 24 individuals (13 females) post-ACLR on three occasions: (1) Early 2.9 (1.1) months; (2) Mid 8.8 (3.1) months; (3) at Return to Sport (RTS) 13.1 (3.6) months; and 29 asymptomatic controls (22 females) once. Time-normalized between-leg asymmetry curves of sagittal plane hip, knee, and ankle moments and vertical ground reaction forces were compared using functional data analysis methods. Individual asymmetrical loading for ACLR was classified when exceeding the 95% confidence interval of controls during ≥50% of the squat. At Early, ACLR had greater asymmetry than controls for knee (15%-100% eccentric phase; 0%-100% concentric) and ankle flexion moments (56%-65% concentric). At Mid, ACLR had greater asymmetry for knee (41%-72% eccentric) and ankle flexion moments (56%-69% concentric). No between-group differences were found at RTS. From Early to RTS, ACLR reduced asymmetry for hip (21%-46% eccentric), knee (27%-58% concentric), and ankle flexion moments (21%-57% eccentric). At Early, 11/24 underloaded their ACLR knee and 1 overloaded compared with controls. At RTS, 4 underloaded and 6 overloaded. No differences in PROMs were found based on loading asymmetry. Beyond the early phase of rehabilitation from ACLR, individual-level analyses are required to reveal differing loading strategies during bilateral squats.

Current Rehabilitation Practices and Return to Sports Criteria After Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists in Saudi Arabia.

CONTEXT: With the high prevalence of anterior cruciate ligament rupture among young and active individuals, rehabilitation after the injury and surgery should meet the current evidence-based recommendations to restore knee function and reduce the risk of further injury. This study aimed to investigate the current rehabilitation practices and return to sports (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) among physical therapists in Saudi Arabia. DESIGN: Online cross-sectional survey-based study. METHODS: A total of 177 physical therapists in Saudi Arabia participated in this survey. The survey included questions about the preferred postoperative timing and frequency of rehabilitation, current views on the importance of preoperative and postoperative rehabilitation to the overall outcomes, the timeframe of RTS, and the decision-making process to RTS. RESULTS: Most therapists (96.6%) believed preoperative rehabilitation was essential/important to postoperative outcomes. Two-thirds encouraged patients to start rehabilitation program within 1 to 4 days immediately post-ACLR. RTS was permitted 6 to 9 months post-ACLR by 60% of therapists if satisfied with patient progress and capacity. Factors considered before RTS included knee strength (72.9%), functional capacity (86.4%), lower limb and trunk mechanics (62.7%), and psychological readiness (42.2%). Knee strength was assessed by manual muscle testing (39%), handheld dynamometry (15.3%), and isokinetic dynamometer (13.6%). While 60% of the therapists used single-limbed hop for distance for evaluating functional capacity, only 27.1% used a hop test battery. CONCLUSIONS: The surveyed physical therapists in Saudi Arabia demonstrated variations in the current rehabilitation practices and RTS criteria post-ACLR. Over half of the surveyed therapists considered preoperative rehabilitation essential to postoperative outcomes. However, the therapists should update their perspective with current evidence-based practice regarding the RTS timeframe, psychological readiness assessment for RTS, and knee strength evaluation using objective measurements.

Postoperative quadriceps weakness and male sex are risk factors for patellofemoral articular cartilage lesions after anatomical anterior cruciate ligament reconstruction.

PURPOSE: Patellofemoral (PF) compartment cartilage lesions are a frequent problem after anterior cruciate ligament (ACL) reconstruction. This study aimed to determine the factors that influence PF cartilage lesions after anatomical ACL reconstruction. METHODS: This study enrolled a total of 114 patients who did not manifest PF compartment cartilage lesions during anatomical ACL reconstruction and underwent second-look arthroscopy 18 months postoperatively. Arthroscopy using the International Cartilage Repair Society (ICRS) classification was used to assess cartilage lesions. The correlation between surgical findings, radiographic factors, and clinical factors and change of ICRS grade was analysed. Multivariate regression analysis was conducted to reveal the independent risk factors for PF cartilage lesions among patients' demographic data and parameters that correlated with the change of ICRS grade in the correlation analyses. RESULTS: ICRS grade changes in PF cartilage were significantly correlated with age, sex, quadriceps strength at 1 year postoperatively, hamstrings strength at pre- and 1 year postoperatively, and single leg hop test at 1 year postoperatively. However, no significant correlation was found between the time between injury and surgery, posterior tibial slope angle, pre- and postoperative Tegner activity scale, graft type, initial graft tension, meniscus injury, meniscus injury treatment, pre- and postoperative range of motion, anteroposterior laxity and preoperative quadriceps strength, and the change in ICRS grade. Multivariate regression analysis revealed male (P = 0.019) and quadriceps strength weakness at 1 year postoperatively (P = 0.009) as independent risk factors for PF cartilage lesions. CONCLUSIONS: Quadriceps strength weakness 1 year after ACL reconstruction and males were correlated with a new PF cartilage lesion after anatomical ACL reconstruction, with no significant correlation between bone-patellar tendon-bone autograft, initial graft tension, or extension deficit and new PF cartilage lesion. Rehabilitation that focuses on quadriceps strength after ACL reconstruction is recommended to prevent new PF cartilage lesions. LEVEL OF EVIDENCE: Level IV.

Factors Associated With Sports Function and Psychological Readiness to Return to Sports at 12 Months After Anterior Cruciate Ligament Reconstruction: A Cross-sectional Study.

BACKGROUND: Sports function and psychological readiness to return to sports (RTS) are important outcomes when evaluating rehabilitation after anterior cruciate ligament reconstruction (ACLR). It is, however, unclear which specific factors contribute most to these outcomes. PURPOSE: To determine associations between demographic characteristics, objective measurements of physical function, patient-reported outcome measure scores, sports-related function assessed with the Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation subscale, and psychological readiness to RTS assessed with the Anterior Cruciate Ligament-Return to Sport after Injury (ACL-RSI) scale at 1 year after ACLR. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: At a mean of 12.5 ± 2.0 months after ACLR, 143 participants (50.3% female), with a mean age of 25.0 ± 5.7 years, were assessed for demographic characteristics, physical factors (hop performance, muscle strength, ankle and hip range of motion), and psychological factors (KOOS Pain and Symptoms subscales, Perceived Stress Scale, fear of reinjury) as well as the KOOS Sport and Recreation subscale and ACL-RSI scale. Backward linear regression models were used to evaluate factors associated with sports function and psychological readiness to RTS. RESULTS: Lower isokinetic knee extension peak torque (limb symmetry index) (B = 18.38 [95% CI, 3.01-33.75]), lower preinjury activity level (B = 2.00 [95% CI, 0.87-3.14]), greater knee pain (B = 0.90 [95% CI, 0.70-1.10]), shorter time between injury and reconstruction (B = 0.16 [95% CI, 0.05-0.26]), and greater fear of reinjury (B = 0.11 [95% CI, 0.01-0.20]) were associated with a worse KOOS Sport and Recreation subscore (R2 = 0.683). A shorter hop distance (B = 0.15 [95% CI, 0.00-0.29]) was associated with a lower ACL-RSI score (R2 = 0.245). CONCLUSION: A combination of knee muscle strength, activity level, knee pain, timing of surgery, and fear of reinjury accounted for approximately 70% of the variation in sports function at 1 year after ACLR. In contrast, there was only 1 weak association between physical function and psychological readiness to RTS at this time point. Thus, factors associated with current sports function are much better known than features related to psychological readiness to RTS.

Effectiveness of a theory-driven mHealth intervention in promoting post-surgery rehabilitation adherence in patients who had anterior cruciate ligament reconstruction: A randomized clinical trial.

RATIONALE: Patients with anterior cruciate ligament (ACL) reconstruction often have poor adherence to post-surgery rehabilitation. OBJECTIVE: This study applied the integrated model of self-determination theory and the theory of planned behavior to examine the effects of a smartphone-delivered intervention on the recovery outcomes of patients with an ACL rupture during post-surgery rehabilitation period. Additionally, we explored the effects of the intervention on participants with different beliefs toward rehabilitation at baseline. METHODS: The randomized control trial recruited 96 eligible participants (M age = 27.82 years, SD = 8.73; female = 39%) who underwent ACL reconstruction surgery. Participants were randomly assigned to an intervention group (n = 41), which received standard post-surgical treatment (usual-care) and smartphone application ("ACL-Well"), or a usual-care control group (n = 55). The primary outcomes were recovery outcomes from ACL surgery measured by knee muscle strength and laxity, and subjective knee evaluation completed 4-month post-intervention. Secondary outcomes were the psychological and behavioral outcomes measured at baseline, at 2- and 4-month post-intervention. RESULTS: ANCOVA indicated no significant between-group differences in primary outcomes: knee muscle strength, knee laxity and subjective knee evaluation, Fs(1, 27 to 55) = 0.01 to 1.36, p = .25 to .99, η2 = 0.01 to 0.03. For the secondary outcomes, growth mixture modelling revealed self-determined treatment motivation declined significantly over the intervention period in the control group (M slope = -0.39 to -0.12, p = .01 to .04), but not in the intervention group (M slope = -0.19 to -0.08, p = .06 to .38). CONCLUSIONS: The smartphone application fell short in promoting orthopedic outpatients' recovery outcomes. Yet, it shows some promises as a mean to maintain patients' motivation and adherence to treatment.

The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction.

CONTEXT: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. METHODS: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. RESULTS: There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval,  1.3 to 10.4; P = .01). CONCLUSION: A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

Quadriceps torque complexity before and after anterior cruciate ligament reconstruction.

OBJECTIVES: The purpose of this project was to longitudinally examine quadriceps torque complexity in a group of individuals who tore their ACL and underwent ACL reconstruction. DESIGN: Cohort analysis. METHODS: Thirty-four individuals completed maximal effort bilateral isometric strength testing after ACL injury but pre-surgery, five months' post-surgery (mid-point of rehabilitation), and when cleared to return to activity. Sample entropy, a nonlinear analysis of quadriceps torque control (complexity), was calculated from maximal isometric contractions. Two 3 × 2 repeated measures analysis of variance were used to examine changes over time and between limbs for quadriceps torque complexity and peak torque. RESULTS: Quadriceps peak torque was lower in the involved limb when compared to the uninvolved limb at every time point (p < 0.001). Peak torque of the involved limb was decreased at mid-point of rehabilitation compared to before surgery (p = 0.023) and at mid-point compared to return to activity (p = 0.041). Quadriceps sample entropy was higher in the involved limb compared to the uninvolved limb at the mid-point of rehabilitation (p < 0.001) and return to activity (p < 0.001), indicating greater complexity. The involved limb also demonstrated increased torque sample entropy from pre-surgery to mid-point of rehabilitation (p = 0.023), but not from pre-surgery to return to activity (p = 0.169) or from mid-point to return to activity (p = 0.541). CONCLUSIONS: Not only does quadriceps strength decline with ACL reconstruction, but quality of the quadriceps muscle contraction is also compromised. Increased torque complexity experienced in the ACL limb after reconstruction may contribute to impaired physical function in individuals following ACL reconstruction.

The ALR-RSI score can be used to evaluate psychological readiness to return to sport after acute Achilles tendon tear.

PURPOSE: The return to sport is one of the main goals following Achilles tendon tear repair. Several psychological factors influence the return to sport after a sports injury. The traditional tools to assess the return to sport do not take into account psychological factors. The ankle ligament reconstruction-return to sport injury (ALR-RSI), validated for ankle instability, is a score to evaluate psychological readiness to return to sport. The goal of this study was to validate the ALR-RSI score for the assessment of the readiness to return to sport after Achilles tendon repair. METHODS: The ALR-RSI score, adapted from the anterior cruciate ligament-return to sport injury (ACL-RSI) score used following knee ligament reconstruction, was validated according to the international COSMIN methodology. Patients operated for Achilles tendon repair responded to the questionnaire during the rehabilitation period. The EFAS, FAAM and VISA-A scores were used as reference questionnaires. RESULTS: A total of 50 patients were included. The ALR-RSI score was strongly (r > 0.5) correlated to the EFAS score: r = 0.68 [0.50-0.80] the FAMM sport score: r = 0.7 [0.52-0.84] the FAAM AVQ score (r = 0.6 [0.35-0.78]), and the VISA-A score (r = 0.54 [0.26-0.76]). The discriminant validity was good with the ALR-RSI, which was significantly lower in the patients that did not return to sport: 60.7 (40-81.4) compared to those that did: 83.2 (64.3-100) p = 0.001. Reproducibility was excellent with an intra-class correlation coefficient ρ of 0.99 [097-1.00]. The internal consistency was excellent (alpha coefficient = 0.95). CONCLUSION: The ALR-RSI score provides a valid, reproducible assessment of the psychological readiness to return to sport in patients who undergo surgical Achilles tendon suture repair. LEVEL OF EVIDENCE: III.

Knee extensor torque-velocity relationships following anterior cruciate ligament reconstruction.

BACKGROUND: The inherent nature of the torque-velocity relationship is the inverse nature between the velocity of muscle contraction and torque production and is an indication of muscle function. The purpose of this study was to characterize the torque-velocity relationship in the quadriceps following anterior cruciate ligament reconstruction compared to healthy limbs. METHODS: 681 participants were included, 493 of which were patients at least four months following anterior cruciate ligament reconstruction (23.2 ± 10.08 yr, 6.6 ± 5.37 months post-surgery) and 188 were healthy participants (21.6 ± 3.77 yr). A subset of 175 post-surgical participants completed a repeated visit (8.1 ± 1.71 months post-surgery). Participants completed isokinetic knee extension at 90°/s and 180°/s. A one-way ANOVA was used to compare torque velocity relationships by limb type (surgical, contralateral, healthy). Paired samples t-tests were conducted to analyze the torque-velocity relationship across limbs and across time. FINDINGS: There was a large effect for limb type on torque-velocity (F(2, 1173) = 146.08, p < 0.001, η2 = 0.20). Surgical limbs demonstrated significantly lower torque-velocity relationships compared to the contralateral limbs (ACLR: 0.26 Nm/kg, contralateral:0.55 Nm/kg, p < 0.001, d = 1.18). Healthy limbs had similar torque-velocity relationships bilaterally (dominant limb: 0.48 Nm/kg, non-dominant limb: 0.49 Nm/kg, p = 0.45). The torque velocity relationship for the involved limb significantly increased in magnitude over time (+0.11 Nm/kg, p < 0.001, d = -0.61) while the contralateral limb torque-velocity relationship remained stable over time (0.0 Nm/kg difference, p = 0.60). INTERPRETATION: Following surgery, the knee extensors appear to have altered torque-velocity relationships compared to contralateral and healthy limbs. This may indicate a specific target for assessment and rehabilitation following surgery.

Investigating the effect of sand training on running mechanics in individuals with anterior cruciate ligament reconstruction and pronated feet.

BACKGROUND: Running on sand could be a method for the rehabilitation of individuals with anterior cruciate ligament reconstruction and pronated feet. However, there is a lack of knowledge about the effects of running on sand on running biomechanics and muscle activities. RESEARCH QUESTION: What is the effect of sand training on running mechanics in individuals with anterior cruciate ligament reconstruction and pronated feet? METHODS: Twenty-eight adult males with anterior cruciate ligament reconstruction and pronated feet were divided into two equal groups (intervention and active control groups). Participants were asked to run at a constant speed of ∼3.2 m/s over an 18 m runway, respectively. Ground reaction forces were recorded using a Bertec force plate. Muscle activities were recorded using a surface bipolar electromyography system. RESULTS: In intervention group but not control group, post-hoc analysis demonstrated significantly longer time-to-peak of impact vertical ground reaction force at post-test than that pre-test (p = 0.047). In intervention group but not control group, post-hoc analysis demonstrated significant decreases of semitendinosus activities during push-off at post-test compared with the pre-test (p = 0.005). SIGNIFICANCE: Sand training improved time-to-peak of ground reaction forces (e.g., time-to-peak of peak of impact vertical ground reaction force) and muscle activities (e.g., semitendinosus activities) in adult males with anterior cruciate ligament reconstruction and pronated feet.

Improving the quality of rehabilitation following anterior cruciate ligament reconstruction surgery, in an outpatient physiotherapy department.

Anterior cruciate ligament reconstruction (ACLR) is a type of orthopaedic knee surgery and physiotherapy rehabilitation is undertaken for several months postoperatively, often with the aim of returning the patient to sport. Variations in postoperative protocols to guide rehabilitation exist between National Health Service (NHS) Trusts. Although there is no single guideline to guide clinicians, strong evidence does support several clinical measures to be included post-ACLR, to improve outcomes and reduce the need for revision surgery. This project aimed to align our NHS Trust's ACLR physiotherapy care with best-evidence.A literature review was completed to establish key quality standards for ACLR rehabilitation. A retrospective notes audit was then undertaken to quantify the baseline quality of care, measured against these standards. Quality improvement methods were used to improve the quality of care and postoperative rehabilitation processes for ACLR patients. A new evidence-based, postoperative rehabilitation protocol was created, a core group of clinicians was formed to see ACLR patients and a rehabilitation class, solely for ACLR patients was also implemented.The key process measure for the project was patients engaging in 'criteria-driven progressions of rehabilitation'. This 'criteria-driven progressions' rate increased from 0% at baseline to 100% during the project period. Overall, non-attendance rates maintained at a similar level from 5.4% at baseline to a final rate of 4.8%. There was also an increase in mean 'return to sport' times, from 6 to 9.9 months, which is in line with best-evidence recommendations.The previous rehabilitation provided in our trust was not aligned with current evidence. This quality improvement project has led to improvements in patient care and lessons from the project will allow other trusts to learn from the changes made, to improve their own care pathways.

[Effect of dietary supplements and whey protein on muscle mass and strength of the operated limb after anterior cruciate ligament reconstruction: a systematic review].

Muscle weakness and atrophy of the quadriceps muscle after anterior cruciate ligament reconstruction may persist for up to 6 months after surgery and cause re-injury to the ipsilateral or contralateral limbs. Many authors state that adequate nutritional status during the rehabilitation period can contribute to faster postoperative recovery of muscle mass and strength of the lower limb, be an adjunct to exercise, or serve an alternative treatment strategy. The purpose of the research was to conduct a systematic review of the literature and evaluate the degree of influence of dietary supplements on muscle mass and strength of the operated limb after reconstruction of the anterior cruciate ligament (ACL). Material and methods. The search for articles was carried out in international databases PubMed, Google Scholar, Cochrane Library. The time frame of the search was 22 years. To be included in the review, studies had to meet the PICOS criteria: participants were men and women over 18 years of age after ACL reconstruction; intervention - supplementation after and/or before and after ACL reconstruction; comparison - placebo group or no supplementary interventions; results - assessment of the dynamics of changes in muscle mass (cross-sectional area, muscle thickness or size of skeletal muscle fibers) and / or maximum strength (dynamic or isometric) of the operated limb; research design - randomized controlled trials (RCT). The quality of selected RCTs was assessed using the Cochrane Collaboration Risk of Bias (RoB 2) tool. Results. A total of 1397 articles were found after searching in the databases. This systematic review included 6 RCTs with a total number of patients 186. The following dietary supplements were used: leucine - 1 article, glucosam ine - 1 article, creatine - 1 article, vitamins E and C - 2 articles. One study evaluated the effect of whey protein supplementation in combination with neuromuscular electrical stimulation on isometric strength of the operated limb. When comparing the data of 3 groups in the pre- and postoperative periods, there were no statistically significant differences between the groups. When considering the protocols for taking dietary supplements based on creatine, glucosamine, vitamins E and C, none of the studies demonstrated statistically significant improvements in the parameters of maximum strength or muscle hypertrophy of the operated limb in the main groups compared with the control groups. Also, no results have been obtained indicating that these dietary supplements can slow down muscl e atrophy after surgery. In another study that evaluated the effect of leucine supplementation, by the end of the rehabilitation program, the muscle strength of the operated limb tended to increase more in the leucine group than in the placebo group, but without a statistically significant difference. At 10 cm from the patella, the femoral circumference of the operated limb in the leucine group increased more than in the placebo group, and the differences were statistically significant (р=0.009). Two studies were rated as high risk of bias, three as moderate risk, and one as low risk. Conclusion. None of the supplements used had a statistically significant effect on the muscle strength of the operated limb after ACL reconstru ction. In terms of thigh muscle hypertrophy, the only significant improvement was associated with leucine supplementation and an increase in thigh circumference at a distance of 10 cm from the patella.

Editorial Commentary: Limited Preoperative Range of Motion Is Associated With Range of Motion Deficits After Anterior Cruciate Ligament Reconstruction: "If the Knee Is Not Straight, Wait".

Optimal timing of anterior cruciate ligament reconstruction (ACLR) remains under debate. Prolonging time between injury and ACLR risks damaging the meniscus and chondral surface, as well as delays return to play. Early ACLR may be associated with postoperative stiffness or arthrofibrosis. We emphasize that optimal timing for ACLR depends on criterion-based return of knee range of motion and quadriceps strength, not a quantitative temporal period. The length of time is far less important that the quality of prereconstruction care provided. Prereconstruction care includes "prehabilitation," including prone hangs focusing on optimizing knee range of motion, postinjury effusion resolution, and mentally preparing the patient for postoperative expectations. Defining preoperative criteria for proceeding with surgery is crucial to decrease the risk of arthrofibrosis. Some patients meet these criteria within 2 weeks, whereas others linger to 10 weeks. Reduction in arthrofibrosis requiring surgical intervention is multifactorial and not solely dependent on the length of time between injury and intervention.