High rate of second ACL injury following ACL reconstruction in male professional footballers: an updated longitudinal analysis from 118 players in the UEFA Elite Club Injury Study.

BACKGROUND: Studies on subsequent anterior cruciate ligament (ACL) ruptures and career length in male professional football players after ACL reconstruction (ACLR) are scarce. AIM: To investigate the second ACL injury rate, potential predictors of second ACL injury and the career length after ACLR. STUDY DESIGN: Prospective cohort study. SETTING: Men's professional football. METHODS: 118 players with index ACL injury were tracked longitudinally for subsequent ACL injury and career length over 16.9 years. Multivariable Cox regression analysis with HR was carried out to study potential predictors for subsequent ACL injury. RESULTS: Median follow-up was 4.3 (IQR 4.6) years after ACLR. The second ACL injury rate after return to training (RTT) was 17.8% (n=21), with 9.3% (n=11) to the ipsilateral and 8.5% (n=10) to the contralateral knee. Significant predictors for second ACL injury were a non-contact index ACL injury (HR 7.16, 95% CI 1.63 to 31.22) and an isolated index ACL injury (HR 2.73, 95% CI 1.06 to 7.07). In total, 11 of 26 players (42%) with a non-contact isolated index ACL injury suffered a second ACL injury. RTT time was not an independent predictor of second ACL injury, even though there was a tendency for a risk reduction with longer time to RTT. Median career length after ACLR was 4.1 (IQR 4.0) years and 60% of players were still playing at preinjury level 5 years after ACLR. CONCLUSIONS: Almost one out of five top-level professional male football players sustained a second ACL injury following ACLR and return to football, with a considerably increased risk for players with a non-contact or isolated index injury.

Systematic video analysis of ACL injuries in professional male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 consecutive cases.

BACKGROUND: A few small studies have reported on the mechanisms of ACL injury in professional male football. AIM: To describe the mechanisms, situational patterns and biomechanics (kinematics) of ACL injuries in professional male football matches. METHODS: We identified 148 consecutive ACL injuries across 10 seasons of professional Italian football. 134 (90%) injury videos were analysed for mechanism and situational pattern, while biomechanical analysis was possible in 107 cases. Three independent reviewers evaluated each video. ACL injury epidemiology (month), timing within the match and pitch location at the time of injury were also reported. RESULTS: 59 (44%) injuries were non-contact, 59 (44%) were indirect contact and 16 (12%) were direct contact. Players were frequently perturbed immediately prior to injury. We identified four main situational patterns for players who suffered a non-contact or an indirect contact injury: (1) pressing and tackling (n=55); (2) tackled (n=24); (3) regaining balance after kicking (n=19); and (4) landing from a jump (n=8). Knee valgus loading (n=83, 81%) was the dominant injury pattern across all four of these situational patterns (86%, 86%, 67% and 50%, respectively). 62% of the injuries occurred in the first half of the matches (p<0.01). Injuries peaked at the beginning of the season (September-October) and were also higher at the end of the season (March-May). CONCLUSIONS: 88% of ACL injuries occurred without direct knee contact, but indirect contact injuries were as frequent as non-contact injuries, underlying the importance of mechanical perturbation. The most common situational patterns were pressing, being tackled and kicking.

Compliance in post-operative rehabilitation is a key factor for return to sport after revision anterior cruciate ligament reconstruction.

PURPOSE: To assess the rate of return to sport (RTS) following revision Anterior Cruciate Ligament Reconstruction (ACLR) in a rehabilitation-based cohort of patients. A secondary goal of the study was to evaluate the association between compliance in post-operative rehabilitation and RTS rate. METHODS: The study cohort included 79 sport-active patients (62 males, 17 females, 30.0 ± 10.2 years old) who underwent revision ACLR surgery and followed the same functional-oriented rehabilitation protocol. Patients were evaluated using a RTS survey: return to any kind of sport participation, return to the same pre-injury sport, return to the same sport at the same pre-injury level. With regards to compliance in post-operative rehabilitation, patients were then grouped in (1) Fully Compliant (FC), (2) Moderately Compliant (MC), (3) Scarcely Compliant (SC), and (4) Non-Compliant (NC). RESULTS: At an average follow-up of 29 ± 12 months, 86% of the patients returned to some kind of sport activity, 62% returned to the same pre-injury sport activity and 59% returned to the same pre-injury level of sport activity. While no surgical aspects were correlated with RTS, higher BMI was found to have a negative influence (p = 0.033). Regardless of the type of sport, compliance significantly affected RTS at the same pre-injury level (p = 0.006): 86% in FC, 67% in MC, 50% in SC, and 45% in NC. For each compliance goal achieved, the probability of RTS increased by 68% (OR = 1.68; p = 0.027). CONCLUSION: RTS at the same pre-injury level after revision ACLR is challenging. A higher compliance in rehabilitation significantly increases the chances of RTS. LEVEL OF EVIDENCE: IV.

After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis.

BACKGROUND: Return to sport and to pre-injury level represents an important outcome after both primary and revision anterior cruciate ligament (ACL) reconstructions. PURPOSE: The aim of the present meta-analysis was to determine the return to sport rate after revision ACL reconstruction. MATERIAL AND METHODS: A systematic search was performed of the MEDLINE, Embase and the Cochrane Central Register of Controlled Trials Databases. All the studies that reported return to sport, return to pre-injury sport level and return to high level/competitive sport was considered for the meta-analysis. The overall pooled mean of post-operative knee laxity and pooled rate of positive pivot-shift and objective International Knee Documentation Committee (IKDC) categories was calculated as well. RESULTS: Overall, 472 abstracts were identified and screened for inclusion and only 16 studies reported the rate of return to any level of sport activity at the final follow-up of 4.7 years (range 1.0-13.2 years), showing a pooled rate of 85.3% (CI 79.7 to 90.2). The return to pre-injury sport level was achieved in 53.4% (CI 37.8 to 68.7) of cases. Normal or quasi-normal objective IKDC, less than 5 mm of side-to-side difference at arthrometric evaluations and grade I-II pivot-shift test were reported in 84%, 88% and 93% patients, respectively. CONCLUSIONS: In spite of almost 8 patients out of 10 returning to sport after revision ACL reconstruction and showing good stability, only half of the patients returned to the same pre-injury sport level.

Revision anterior cruciate ligament reconstruction: clinical outcome and evidence for return to sport.

PURPOSE: An increasing number of patients undergo revision anterior cruciate ligament (ACL) reconstruction, with the intention of returning to sport being a major indication. The aim of this study is to assess the available evidence for clinical improvement and return to sport, to understand the real potential of this procedure in regaining functional activity, and to facilitate improved counselling of patients regarding the expected outcome after revision ACL reconstruction. METHODS: The search was conducted on the PubMed database. Articles reporting clinical results for revision ACL reconstruction were included. A meta-analysis was performed on return to sport, and results were compared to the literature on primary ACL reconstruction. Other specific clinical outcomes (Lysholm, Tegner, IKDC Objective scores) were also included in the meta-analysis. RESULTS: Of the 503 identified records, a total of 59 studies involving 5365 patients were included in the qualitative data synthesis. Only 31 articles reported the rate of return to sport. Whereas 73 % of good objective results and satisfactory subjective results were documented, 57 % of patients did not return to the same level of sport activity, significantly inferior to that of a primary procedure. CONCLUSION: The real potential of revision ACL reconstruction should not be overestimated due to the low number of patients able to return to their previous activity level, significantly inferior with respect to that reported for primary ACL reconstruction. This finding will help physicians in the clinical practice providing realistic expectations to the patients. Future studies should focus on participation-based outcome measures such as return to sport and in strategies to improve the results in terms of return to previous activities after revision ACL reconstruction. LEVEL OF EVIDENCE: Systematic review and meta-analysis including Level IV studies, Level IV.

Open versus arthroscopic surgical treatment of chronic proximal patellar tendinopathy. A systematic review.

PURPOSE: A general agreement on the best surgical treatment option of chronic proximal patellar tendinopathy is still lacking. The purpose of this systematic review was to investigate if arthroscopically assisted procedures have been reported better results compared to open surgery and to assess the methodology of studies. METHODS: Twenty-one studies were included in the review. Surgical outcomes were defined referring to the functional classification described by Kelly et al. (Am J Sports Med 12(5):375-380, [11]): return to sport was regarded as the ability of training at the original level before injury with mild or moderate pain and success as the improvement after surgery with symptom reduction. Methodological analysis was performed by two reviewers adopting the Coleman Methodology Score (CMS) (range 0-100, best score 100). RESULTS: Only one randomized controlled trial (RCT) met inclusion criteria; all other included studies were case series. Median sample size 24, range 11-138, mean age at surgery 26.8 ± 3.2 years, mean follow-up 32.5 ± 18.4 (median 31, range 6-60) months. Return to sport rate: global 78.5 %, open group 76.6 % and arthroscopic group 84.2 %. Success rate: global 84.6 %, open group 87.2 % and arthroscopic group 92.4 %. Differences between groups were not statistically significant. CMSs were positively correlated with the year of publication (P < 0.05). CONCLUSIONS: Minimally invasive arthroscopically assisted procedures have not reported better statistically significant results when compared to open surgery in the treatment of chronic proximal patellar tendinopathy. The methodology of studies in this field has improved over the past 15 years, but well-designed RCTs using validated patient-based outcome measures are still lacking. LEVEL OF EVIDENCE: Systematic Review, Level IV.

Non-surgical management of early knee osteoarthritis.

Conservative approach is usually the first choice for the management of the knee degeneration processes, especially in the phase of the disease recognized as early osteoarthritis (OA) with no clear lesions or associated abnormalities requiring to be addressed surgically. A wide spectrum of treatments is available, from non-pharmacological modalities to dietary supplements and pharmacological therapies, as well as minimally invasive procedures involving injections of various substances aiming to restore joint homeostasis and provide clinical improvement and possibly a disease-modifying effect. Numerous pharmaceuticals have been proposed, but since no therapy has shown all the characteristic of an ideal treatment, and side effects have been reported at both systemic and local level, the use of pharmacological agents should be considered with caution by assessing the risk/benefit ratio of the drugs prescribed. Both patients and physicians should have realistic outcome goals in pharmacological treatment, which should be considered together with other conservative measures. A combination of these therapeutic options is a more preferable scenario, in particular considering the evidence available for non-pharmacological management. In fact, exercise is an effective conservative approach, even if long-term effectiveness and optimal dose and administration modalities still need to be clarified. Finally, physical therapies are emerging as viable treatment options, and novel biological approaches are under study. Further studies to increase the limited medical evidence on conservative treatments, optimizing results, application modalities, indications, and focusing on early OA will be necessary in the future. Level of evidence IV.

Use of platelet-rich plasma for the treatment of refractory jumper's knee.

The aim of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy after previous classical treatments have failed. We treated 15 patients affected by chronic jumper's knee, who had failed previous nonsurgical or surgical treatments, with multiple PRP injections and physiotherapy. We also compared the clinical outcome with a homogeneous group of 16 patients primarily treated exclusively with the physiotherapy approach. Multiple PRP injections were performed on three occasions two weeks apart into the site of patellar tendinopathy. Tegner, EQ VAS and pain level were used for clinical evaluation before, at the end of the treatment and at six months follow-up. Complications, functional recovery and patient satisfaction were also recorded. A statistically significant improvement in all scores was observed at the end of the PRP injections in patients with chronic refractory patellar tendinopathy and a further improvement was noted at six months, after physiotherapy was added. Moreover, comparable results were obtained with respect to the less severe cases in the EQ VAS score and pain level evaluation, as in time to recover and patient satisfaction, with an even higher improvement in the sport activity level achieved in the PRP group. The clinical results are encouraging, indicating that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.

Clinical Outcomes After Anterior Cruciate Ligament Injury: Panther Symposium ACL Injury Clinical Outcomes Consensus Group.

A stringent outcome assessment is a key aspect of establishing evidence-based clinical guidelines for anterior cruciate ligament (ACL) injury treatment. To establish a standardized assessment of clinical outcome after ACL treatment, a consensus meeting including a multidisciplinary group of ACL experts was held at the ACL Consensus Meeting Panther Symposium, Pittsburgh, Pennsylvania, USA, in June 2019. The aim was to establish a consensus on what data should be reported when conducting an ACL outcome study, what specific outcome measurements should be used, and at what follow-up time those outcomes should be assessed. The group reached consensus on 9 statements by using a modified Delphi method. In general, outcomes after ACL treatment can be divided into 4 robust categories: early adverse events, patient-reported outcomes (PROs), ACL graft failure/recurrent ligament disruption, and clinical measures of knee function and structure. A comprehensive assessment after ACL treatment should aim to provide a complete overview of the treatment result, optimally including the various aspects of outcome categories. For most research questions, a minimum follow-up of 2 years with an optimal follow-up rate of 80% is necessary to achieve a comprehensive assessment. This should include clinical examination, any sustained reinjuries, validated knee-specific PROs, and health-related quality of life questionnaires. In the midterm to long-term follow-up, the presence of osteoarthritis should be evaluated. This consensus paper provides practical guidelines for how the aforementioned entities of outcomes should be reported and suggests the preferred tools for a reliable and valid assessment of outcome after ACL treatment.

On-field Rehabilitation Part 1: 4 Pillars of High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restoring Sport-Specific Skills, and Progressively Developing Chronic Training Load.

SYNOPSIS: Outcomes following long-term injuries such as anterior cruciate ligament rupture are unsatisfactory. To improve outcomes, we must improve rehabilitation practices. One aspect of the return-to-sport process that has received limited attention is on-field rehabilitation. This article is part 1 of a 2-part series aimed at discussing the important elements of on-field rehabilitation and illustrating how they can be applied across a 5-stage on-field rehabilitation program following anterior cruciate ligament reconstruction. The intention of on-field rehabilitation is to support athletes in their transition back to sport after injury, from standard rehabilitation to return to the team or practice. In part 1, we describe 4 pillars of high-quality on-field rehabilitation: (1) restoring movement quality, (2) physical conditioning, (3) restoring sport-specific skills, and (4) progressively developing chronic training load. In part 2, we describe how these pillars may be combined into a 5-stage on-field rehabilitation program to help athletes transition to team practice and match play following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 2019;49(8):565-569. doi:10.2519/jospt.2019.8954.

On-field Rehabilitation Part 2: A 5-Stage Program for the Soccer Player Focused on Linear Movements, Multidirectional Movements, Soccer-Specific Skills, Soccer-Specific Movements, and Modified Practice.

SYNOPSIS: This paper is part 2 of a 2-part series aimed at discussing the key elements of on-field rehabilitation training. In part 1, we described 4 pillars underpinning high-quality on-field rehabilitation: (1) restoring movement quality, (2) physical conditioning, (3) restoring sport-specific skills, and (4) progressively developing chronic training load. In part 2, we describe how the pillars contribute to a 5-stage on-field rehabilitation program to help injured players transition to team practice and match play. We use the example of a soccer player with ambitions to return to sport after anterior cruciate ligament reconstruction. The program moves through 5 field-based training stages: (1) linear movement, (2) multidirectional movement, (3) soccer-specific technical skills, (4) soccer-specific movement, and (5) practice simulation. The staged program is research based and facilitates communication, planning, control, and safety in return to sport following long-term injury. J Orthop Sports Phys Ther 2019;49(8):570-575. doi:10.2519/jospt.2019.8952.

Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline.

BACKGROUND: A small number of randomized controlled trials have found ultrasound-guided injection of platelet-rich plasma (PRP) to be no more effective than saline for several tendinopathies; limited information exists for patellar tendinopathy. In addition, different PRP formulations that produce varying concentrations of leukocytes have not been directly compared for patellar tendinopathy. PURPOSE/HYPOTHESIS: To determine if a single ultrasound-guided PRP injection, either leukocyte-rich PRP (LR-PRP) or leukocyte-poor PRP (LP-PRP), was superior to saline injection for the treatment of patellar tendinopathy. The null hypothesis was that no treatment would be superior to another for the treatment of patellar tendinopathy. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Athletes with patellar tendinopathy for ≥6 months (Blazina stage IIIB) were assessed for eligibility in a multisite single-blind controlled trial. There were 3 injection arms: LR-PRP, LP-PRP, and saline. Patients received a single ultrasound-guided injection, followed by 6 weeks of supervised rehabilitation (heavy slow resistance training, concentric and eccentric, 3 times per week). Outcome measures-Victorian Institute of Sport Assessment (patellar; VISA-P), pain during activity, and global rating of change-were assessed at 6 and 12 weeks and 6 and 12 months. VISA-P score at 12 weeks was the primary outcome. Fifty-seven patients (19 in each group) were included in an intention-to-treat analysis. Secondary outcome measures included pain during activity and patients' global rating of change. RESULTS: Study retention was 93% at 12 weeks and 79% after 1 year. There was no significant difference in mean change in VISA-P score, pain, or global rating of change among the 3 treatment groups at 12 weeks or any other time point. After 1 year, the mean (SD) outcomes for the LR-PRP, LP-PRP, and saline groups were as follows, respectively: VISA-P-58 (29), 71 (20), and 80 (18); pain-4.0 (2.4), 2.4 (2.3), and 2.0 (1.9); global rating of change-4.7 (1.6), 5.6 (1.0), and 5.7 (1.2) ( P > .05 for all outcomes). CONCLUSION: Combined with an exercise-based rehabilitation program, a single injection of LR-PRP or LP-PRP was no more effective than saline for the improvement of patellar tendinopathy symptoms. REGISTRATION: NCT02116946 (ClinicalTrials.gov identifier).

Return to Sports after Articular Cartilage Repair in the Football (Soccer) Player.

BACKGROUND: The ability to return to football (soccer) presents a critical aspect for successful treatment of articular cartilage injury in the football (soccer) player. METHODS: Information about sports participation after articular cartilage repair was collected from the literature. Special focus was placed on data in football athletes with information on return rate, timing of return, level of postoperative competition, and the ability to compete in the sport over time. RESULTS: Twenty studies describing 1,469 athletes including football players with articular cartilage injury were reviewed. Average return to sport was 79% without a significant difference in return rate or postoperative level of play between cartilage repair techniques. Time to return varied between 7 to 17 months, with the longest time for autologous chondrocyte transplantation (ACI). Advanced sport-specific rehabilitation was able to reduce recovery time. Durability of results was best after ACI, with up to 96% continued sport participation after more than 3 years. Player age, time between injury and treatment, competitive level, defect size, and repair tissue morphology affected the ability to return to play. Sports participation after cartilage repair generally promoted joint restoration and functional recovery. CONCLUSIONS: Articular cartilage repair allows for a high rate of return to high-impact sports including football, often at the preinjury competitive level. The time of return and durability can be variable and depend on repair technique and athlete-specific factors. Advanced, sport-specific rehabilitation can facilitate return to football.

Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete.

Articular cartilage injury is observed with increasing frequency in both elite and amateur athletes and results from the significant acute and chronic joint stress associated with impact sports. Left untreated, articular cartilage defects can lead to chronic joint degeneration and athletic and functional disability. Treatment of articular cartilage defects in the athletic population presents a therapeutic challenge due to the high mechanical demands of athletic activity. Several articular cartilage repair techniques have been shown to successfully restore articular cartilage surfaces and allow athletes to return to high-impact sports. Postoperative rehabilitation is a critical component of the treatment process for athletic articular cartilage injury and should take into consideration the biology of the cartilage repair technique, cartilage defect characteristics, and each athlete's sport-specific demands to optimize functional outcome. Systematic, stepwise rehabilitation with criteria-based progression is recommended for an individualized rehabilitation of each athlete not only to achieve initial return to sport at the preinjury level but also to continue sports participation and reduce risk for reinjury or joint degeneration under the high mechanical demands of athletic activity.

Clinical Outcomes and Return-to-Sports Participation of 50 Soccer Players After Anterior Cruciate Ligament Reconstruction Through a Sport-Specific Rehabilitation Protocol.

BACKGROUND: Rehabilitation of soccer players after anterior cruciate ligament reconstruction is usually performed without sport-specific guidelines, and the final phases are often left to the team coaches. The possibility of changing this approach has not yet been investigated. STUDY DESIGN: Case series. HYPOTHESIS: A specific rehabilitation protocol for soccer players, with direct control of the last on-field rehabilitation phases, may lead to complete functional recovery. METHODS: Fifty competitive soccer players who followed a sport-specific rehabilitation protocol for soccer were evaluated during the recovery period until their return to competition. The assessment of the functional outcomes was performed using the Knee Outcome Survey-Sports Activity Scale and isokinetic and aerobic fitness tests. RESULTS: The average start of on-field rehabilitation was 90 ± 26 days after surgery; the average time to return to the competitions was 185 ± 52 days. The improvement in the Knee Outcome Survey-Sports Activity Scale during on-field rehabilitation was significant (P < 0.01; from 79 ± 15% to 96 ± 7%). The isokinetic and aerobic fitness tests showed a significant improvement of muscle strength (knee extensors, +55%, P < 0.01; knee flexors, +86%, P < 0.01) and aerobic threshold (+23%, P < 0.01) from the beginning to the end of on-field rehabilitation. CONCLUSIONS: Adding on-field rehabilitation to the traditional protocols after anterior cruciate ligament reconstruction may safely lead to complete functional recovery in soccer players.

Articular cartilage treatment in high-level male soccer players: a prospective comparative study of arthroscopic second-generation autologous chondrocyte implantation versus microfracture.

BACKGROUND: Soccer is a highly demanding sport for the knee joint, and chondral injuries can cause disabling symptoms that may jeopardize an athlete's career. Articular cartilage lesions are difficult to treat, and the increased mechanical stress produced by this sport makes their management even more complex. HYPOTHESIS: To evaluate whether the regenerative cell-based approach allows these highly demanding athletes a better functional recovery compared with the bone marrow stimulation approach. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Forty-one professional or semiprofessional male soccer players were treated from 2000 to 2006 and evaluated prospectively at 2 years and at a final 7.5-year mean follow-up (minimum, 4 years). Twenty-one patients were treated with arthroscopic second-generation autologous chondrocyte implantation (Hyalograft C) and 20 with the microfracture technique. The clinical outcome of all patients was analyzed using the cartilage standard International Cartilage Repair Society (ICRS) evaluation package. The sport activity level was evaluated with the Tegner score, and the recovery time was also recorded. RESULTS: A significant improvement in all clinical scores from preoperative to final follow-up was found in both groups. The percentage of patients who returned to competition was similar: 80% in the microfracture group and 86% in the Hyalograft C group. Patients treated with microfracture needed a median of 8 months before playing their first official soccer game, whereas the Hyalograft C group required a median time of 12.5 months (P = .009). The International Knee Documentation Committee (IKDC) subjective score showed similar results at 2 years' follow-up but significantly better results in the Hyalograft C group at the final evaluation (P = .005). In fact, in the microfracture group, results decreased over time (from 86.8 ± 9.7 to 79.0 ± 11.6, P < .0005), whereas the Hyalograft C group presented a more durable outcome with stable results (90.5 ± 12.8 at 2 years and 91.0 ± 13.9 at the final follow-up). CONCLUSION: Despite similar success in returning to competitive sport, microfracture allows a faster recovery but present a clinical deterioration over time, whereas arthroscopic second-generation autologous chondrocyte implantation delays the return of high-level male soccer players to competition but can offer more durable clinical results.