Reasons for Not Returning to Pre-injury Sport Level After ACL-Reconstruction.

The study aimed to identify athlete-reported reasons for not returning to pre-injury sports level after anterior cruciate ligament reconstruction (ACLR) and to identify the factors associated with these reasons. Ninety-one athletes with 2 years post-ACLR indicated whether or not they had returned to their pre-injury sport level (same frequency, duration, and intensity). Athletes who did not return were asked to provide the reasons. Athletes' characteristics and injury-related factors were used to determine factors associated with the reasons for not returning. Only nine athletes (10%) returned to pre-injury sport level after ACLR. The most common reasons for not returning were lack of confidence or concerns about re-injury (48.8%), followed by continued post-surgical impairments in the reconstructed knee (39%). Having episodes of the knee giving way after ACLR was the only significant predictor of post-surgical impairments (48.8%; OR=8.3, 95%CI=2.48-27.42, p=0.001). Lack of confidence, concerns about re-injury, or post-surgical impairments in the reconstructed knee were the most frequently reported reasons for not returning to pre-injury sports level with 2 years post-ACLR. Reported dynamic knee instability was the only factor associated with ongoing post-surgical knee impairments after ACLR. Rehabilitation programs should address athletes' psychological responses and resolve knee impairments to optimize return to pre-injury sport level after ACLR.

Clinical and Biomechanical Efficacies of Mechanical Perturbation Training After Anterior Cruciate Ligament Rupture.

CONTEXT: Manual perturbation training improves knee functional performance and mitigates abnormal gait in patients with anterior cruciate ligament (ACL) rupture. However, manual perturbation training is time- and labor-intensive for therapists. OBJECTIVE: To investigate whether perturbation training administered using a mechanical device can provide effects similar to manual training on clinical measures and knee biomechanics after ACL rupture. DESIGN: Prospective cohort (therapeutic) study. A 2 × 2 analysis of variance was used for statistical analysis. SETTING: A clinical and biomechanical laboratory. PATIENTS: Eighteen level I/II patients with acute ACL ruptures participated in this preliminary study. INTERVENTION: Nine patients received mechanical perturbation training on an automated mechanical device (mechanical group), and 9 patients received manual perturbation training (manual group). OUTCOME MEASURES: Patients completed performance-based testing (quadriceps strength and single-legged hop tests), patient-reported questionnaires (Knee Outcome Survey-Activities of Daily Living Scale, Global Rating Score, and International Knee Documentation Committee 2000), and 3-dimensional gait analysis before (pretesting) and after (posttesting) training. RESULTS: There was no significant group-by-time interaction found for all measures (P ≥ .18). Main effects of time were found for International Knee Documentation Committee 2000 (pretesting: 69.10 [10.95], posttesting: 75.14 [7.19]), knee excursion during weight-acceptance (pretesting: 16.01° [3.99°]; posttesting: 17.28° [3.99°]) and midstance (pretesting: 14.78° [4.13°]; posttesting: 16.92° [4.53°]) and external knee-flexion moment (pretesting: 0.43 [0.11] N m/kg/m; posttesting: 0.48 [0.11] N m/kg/m) (P ≤ .04). After accounting for pretesting groups' differences, the mechanical group scored significantly higher on triple hops (mechanical: 96.73% [6.65%]; manual: 84.97% [6.83%]) and 6-m timed hops (mechanical: 102.07% [9.50%]; manual: 91.21 [9.42%]) (P ≤ .047) compared with manual group. CONCLUSION: The clinical significance of this study is the mechanical perturbation training produced effects similar to manual training, with both training methods were equally  effective at improving patients' perception of knee function and increasing knee excursion and external flexion moment during walking after acute ACL rupture. Mechanical perturbation training is a potential treatment to improve patients' functional and biomechanical outcomes after ACL rupture.

Functional performance 6 months after ACL reconstruction can predict return to participation in the same preinjury activity level 12 and 24 months after surgery.

BACKGROUND: Assessing athletes' readiness is a key component for successful outcomes after ACL reconstruction (ACLR). OBJECTIVES: To investigate whether return-to-activity criteria, individually or in combination, at 6 months after ACLR can predict return to participation in the same preinjury activity level at 12 and 24 months after ACLR. METHODS: Ninety-five level I/II participants completed return-to-activity criteria testing (isometric quadriceps index, single-legged hop tests, Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS) and Global Rating Score (GRS)) at 6 months after ACLR. The PASS group was defined as scoring >90% on all criteria and the FAIL group as scoring <90% on any criteria. At 12 and 24 months after ACLR, participants were asked if they had returned to participate in the same preinjury activity level or not. All return-to-activity criteria, except quadriceps index, were entered into the logistic regression model. RESULTS: 81% and 84.4% of the PASS group returned to participation in the same preinjury activity level, while only 44.2% and 46.4% of the FAIL group returned at 12 and 24 months, respectively, after ACLR. The 6-meter timed hop, single hop and triple hop limb symmetry indexes; GRS; and KOS-ADLS individually predicted the outcome of interest at 12 months after ACLR (range: R2: 0.12-0.22, p<0.024). In combination, they explained 27% of the variance (p=0.035). All hop tests, individually, predicted the outcome of interest at 24 months after ACLR (range: R2: 0.26-0.37; p<0.007); in combination they explained 45% of the variance (p<0.001). CONCLUSION: Return to participation in the same preinjury activity level at 12 and 24 months after ACLR was higher in those who passed the criteria compared with those who failed. Individual and combined return-to-activity criteria predicted the outcomes of interest, with the hop tests as consistent predictors at 12 and 24 months after ACLR.

Consensus criteria for defining 'successful outcome' after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation.

BACKGROUND: No gold standard exists for identifying successful outcomes 1 and 2 years after operative and non-operative management of anterior cruciate ligament (ACL) injury. This limits the ability of a researcher and clinicians to compare and contrast the results of interventions. PURPOSE: To establish a consensus based on expert consensus of measures that define successful outcomes 1 and 2 years after ACL injury or reconstruction. METHODS: Members of international sports medicine associations, including the American Orthopaedic Society for Sports Medicine, the European Society for Sports Traumatology, Surgery, and Knee Arthroscopy and the American Physical Therapy Association, were sent a survey via email. Blinded responses were analysed for trends with frequency counts. A summed importance percentage (SIP) was calculated and 80% SIP operationally indicated consensus. RESULTS: 1779 responses were obtained. Consensus was achieved for six measures in operative and non-operative management: the absence of giving way, patient return to sports, quadriceps and hamstrings' strength greater than 90% of the uninvolved limb, the patient having not more than a mild knee joint effusion and using patient-reported outcomes (PRO). No single PRO achieved consensus, but threshold scores between 85 and 90 were established for PROs concerning patient performance. CONCLUSIONS: The consensus identified six measures important for successful outcome after ACL injury or reconstruction. These represent all levels of the International Classification of Functioning: effusion, giving way, muscle strength (body structure and function), PRO (activity and participation) and return to sport (participation), and should be included to allow for comparison between interventions.

Sex differences in patients with different stages of knee osteoarthritis.

OBJECTIVE: To quantify the differences in physical impairments and in performance-based measures and patient-reported outcomes in men and women seeking nonoperative management of symptomatic moderate knee osteoarthritis (OA) and those with symptomatic end-stage knee OA scheduled for total knee arthroplasty compared with healthy controls. DESIGN: Cross-sectional analysis of individuals referred to physical therapy, community participants, and subjects from a 2-year longitudinal study. SETTING: University research department. PARTICIPANTS: Cross-sectional analysis of participants (N=289) consisting of a moderate OA group (n=83), a severe OA group (n=143), and a healthy control group (n=63). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Quadriceps strength, timed Up and Go test, stair-climbing test, 6-minute walk test, Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS), and Physical Component Summary (PCS) of the Medical Outcomes Study 36-Item Short-Form Health Survey. RESULTS: Women had worse scores than men for physical impairment and performance-based measures (P<.001). In the moderate OA group, women had significantly lower KOS-ADLS (P=.007) and PCS (P=.026) scores than men, with no differences seen between sexes in the other 2 groups for patient-reported measures. CONCLUSIONS: Differences between women and men with knee OA on physical impairments and performance-based measures are not echoed in the differences seen in patient-reported measures. These measures signal different domains of knee function in patients with knee OA and should be used as part of a comprehensive functional evaluation.

Symmetry restoration and functional recovery before and after anterior cruciate ligament reconstruction.

PURPOSE: The aims of this study were to evaluate the functional recovery before and after ACL reconstruction and to evaluate the sensitivity to change in performance-based and self-reported outcomes prior to and after ACL reconstruction and to determine whether these changes represent clinically relevant improvement. METHODS: Eighty-three athletes participated in this study. Athletes were tested after an ACL injury, after preoperative training, and 6 and 12 months after ACL reconstruction. Athletes completed quadriceps strength testing, hop testing, and self-reported questionnaires for knee function (International Knee Documentation Committee subjective knee form, Knee Outcome Survey-Activities of Daily Living Scale, and the Global Rating Scale of Perceived Function) at each testing period. RESULTS: A significant interaction of limb by time was seen in normalized quadriceps strength, and single, triple, and 6-m timed hop, where the involved limb improved more than the uninvolved limb over time. A main effect of time was noted for performance-based limb symmetry indexes and self-reported measures. CONCLUSION: Limb-to-limb asymmetries are reduced, and normal limb symmetry is restored after perturbation training and aggressive quadriceps strengthening and returned to similar levels 6 months after reconstruction. Performance-based values on the involved limb and self-reported outcomes are sensitive to change over time, and these were clinically relevant improvements.

Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention.

The Academy of Orthopaedic Physical Therapy and the American Academy of Sports Physical Therapy have an ongoing effort to create evidence-based clinical practice guidelines (CPGs) for orthopaedic and sports physical therapy management and prevention of musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability and Health (ICF). This guideline focuses on the exercise-based prevention of knee injuries and provides an update on the 2018 guideline, J Orthop Sports Phys Ther. 2018;48(9):A1-A42. doi:10.2519/jospt.2018.0303 J Orthop Sports Phys Ther. 2023;53(1):CPG1-CPG34. doi:10.2519/jospt.2023.0301.

Recommendations for Psychosocial Evaluation of VAD candidates: Adoption, completion, and barriers to implementation.

BACKGROUND: Recommendations exist to guide clinicians on a comprehensive psychosocial (PS) evaluation prior to Mechanical Circulatory Support (MCS) implantation. OBJECTIVES: Assess adoption, beliefs, methodologies, and barriers to completion of the 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for Psychosocial evaluation of adult cardiothoracic transplant and long term mechanical circulatory support. METHODS: Cross-sectional survey distributed to all 183 implanting LVAD centers in North America via mail and email. RESULTS: Total of 58 Programs (35.6% response rate) representing 29 states and all regions of the United States responded. Respondents reported implanting 1,183 adults (range 0 - 85; mean = 21.5, SD = 18) in 2018. A majority (n = 55, 94.8%) reported that the 2018 Recommendations were consistent with their clinical practice and most (n = 51, 87.9%) had adopted the recommendations. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) (n = 25, 47.1%) was the most commonly cited assessment tool in the use, although 15 centers reported utilizing more than one tool during the assessment process. Most common barriers influencing completion of the PS evaluation include patient too ill (total responses = 104), lack of time (total responses = 89), patient poor candidate (total responses = 44), and lack of Insurance coverage/reimbursement (total responses = 41). CONCLUSION: The 2018 ISHLT Recommendations for PS evaluation of LVAD Candidates are widely adopted by respondents in clinical practice, although barriers are still reported to their implementation. Additional research is needed to understand strategies to reduce barriers to implementation and maintenance of the recommendations in clinical practice.

Association of Quadriceps Strength Symmetry and Surgical Status With Clinical Osteoarthritis Five Years After Anterior Cruciate Ligament Rupture.

OBJECTIVE: The objective of this study was to examine the association of quadriceps strength symmetry and surgical status (anterior cruciate ligament [ACL] reconstruction or nonoperative management) with early clinical knee osteoarthritis (OA) 5 years after ACL injury or reconstruction. METHODS: In total, 204 of 300 athletes were analyzed 5 years after ACL injury or reconstruction. Quadriceps strength was measured and reported as a limb symmetry index. We identified participants with early clinical knee OA using the criteria that 2 of 4 Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales score ≤85%. We calculated odds ratios (ORs) and 95% confidence intervals (95% CIs) using logistic regression and adjusted for age, sex, meniscal injury, and body mass index to examine the associations of quadriceps strength and surgical status with clinical knee OA. RESULTS: In all, 21% of participants met the KOOS criteria for clinical knee OA. For every 1% increase in quadriceps limb symmetry index, there was a 4% lower odds of clinical OA (adjusted OR [ORadj ] 0.96 [95% CI 0.93-0.99]) at 5 years. Surgical status was not associated with clinical knee OA (ORadj 0.58 [95% CI 0.23-1.50]). CONCLUSION: More symmetric quadriceps strength, but not surgical status, 5 years after ACL injury or reconstruction was associated with lower odds of clinical knee OA.

Effects of and Response to Mechanical Loading on the Knee.

Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.

Perceived barriers to implementation of injury prevention programs among collegiate women's soccer coaches.

OBJECTIVES: Knee injury prevention programs (IPPs) reduce knee and anterior cruciate ligament (ACL) injury rates in female athletes, however, implementation of IPPs is low. The purpose of this study was to identify barriers to implementation of IPPs among collegiate women's soccer coaches. DESIGN: Cross-sectional survey. METHODS: A custom survey based on the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework and existing literature was sent to 151 out of 153 women's National Collegiate Athletic Association (NCAA) soccer coaches in the NCAA's Eastern Region. RESULTS: Ten respondents reported that they did not use an IPP (Non-users), and nineteen respondents reported that they did use an IPP (Users). "Cost" was the most highly ranked barrier (median rank: 2) to implementing an IPP among Non-users. For the statement, "Who should be responsible for completing an IPP," Users said "Coaches" (47%) and "Other" (21%), while Non-users said "Strength and conditioning" (50%) and "Athletic trainers" (30%). Respondents who marked "Other", elaborated that it was the responsibility of coaches, athletes, and additional staff members. CONCLUSIONS: Cost was the primary barrier to implementation of an IPP. Since the majority of Non-users indicated that implementation of an IPP was the responsibility of a non-coaching staff member, cost may be a surrogate for the expense of hiring an additional staff member rather than the cost of performing the IPP itself. Additionally, using a team-based approach that encompasses athletes, coaches, and non-coaching staff members may support long-term implementation of IPPs.

Rehabilitation duration and time of starting sport-related activities associated with return to the previous level of sports after anterior cruciate ligament reconstruction.

OBJECTIVES: To determine predictors for return to previous level of sports after anterior cruciate ligament reconstruction (ACLR). DESIGN: Cross-sectional; SETTING: Athletic teams. PARTICIPANTS: Ninety-one athletes who had ACLR with hamstring-tendon autograft within 1-5 years participated in this study. Athletes indicated their sport participation levels, injury profile, rehabilitation duration, and time to start sport-related activities (running, cutting-pivoting) after ACLR. Athletes answered whether they returned to the same previous level of frequency, duration, and intensity of sports. MAIN OUTCOME MEASURES: Athletes' characteristics, injury and surgical factors, duration of post-operative rehabilitation program, and time to start sport-related activities after ACLR were evaluated by univariate logistic regression to determine predictors for return to previous level of sports. RESULTS: Nine athletes (10%) returned to their self-described previous level of sports. Predictors for returning to previous level of sports were rehabilitation duration >4 months (OR:6.78; p = .011), time to start running ≤4 months (OR:8.62; p = .047) and cutting-pivoting <6 months after surgery (OR:5.02; p = .030). CONCLUSION: Longer post-operative rehabilitation duration and time to start sport-related activities after ACLR predicted return to previous level of sports. Spending adequate time in post-operative rehabilitation program and time-based resumption of sports-related activities after ACLR might be key factors for returning to previous sports level.

Knee pain and mobility impairments: meniscal and articular cartilage lesions.

The Orthopaedic Section of the American Physical Therapy Association presents this fifth set of clinical practice guidelines on knee pain and mobility impairments, linked to the International Classification of Functioning, Disability, and Health (ICF). The purpose of these practice guidelines is to describe evidence-based orthopaedic physical therapy clinical practice and provide recommendations for (1) examination and diagnostic classification based on body functions and body structures, activity limitations, and participation restrictions, (2) interventions provided by physical therapists, (3) and assessment of outcome for common musculoskeletal disorders.

Physical Therapist Management of Total Knee Arthroplasty.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

Rehabilitation and functional outcomes in collegiate wrestlers following a posterior shoulder stabilization procedure.

STUDY DESIGN: Case series. CASE DESCRIPTION: Five consecutive collegiate Division I wrestlers, with a mean age of 20.2 years (range, 18-22 years), were treated postsurgical stabilization to address posterior glenohumeral joint instability. All received physical therapy postoperatively, consisting of range-ofmotion, strengthening, and plyometrics exercises, neuromuscular re-education, and sport-specific training. Functional outcome scores using the Penn Shoulder Score questionnaire were recorded at postsurgical initial evaluation and discharge. Isometric shoulder strength, measured with a handheld dynamometer at discharge, was compared with measurements made during preseason screening. OUTCOMES: Postsurgery, upon initial physical therapy evaluation, scores on the Penn Shoulder Score questionnaire ranged from 37 to 74 out of 100. All 5 wrestlers improved with rehabilitation such that their scores at discharge ranged from 81 to 91 out of 100. Mean external rotation-internal rotation strength ratio for the involved shoulder was 73.5% (range, 55.9%-88.7%) preseason and 80.9% (range, 70.2%-104.1%) postrehabilitation. Four patients were able to return to wrestling over a period of 1 season, with no episodes of reinjury to their surgically repaired shoulder. DISCUSSION: Current research on posterior glenohumeral instability is limited, due to the relatively rare diagnosis and infrequent need for surgical intervention. Providing a structured physical therapy program following this surgical procedure appeared to have assisted in a return to full functional activities and sports. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2009;39(7):550-559, Epub 24 February 2009. doi:10.2519/jospt.2009.2952.

THE EFFECT OF TRAINING ON A COMPLIANT SURFACE ON MUSCLE ACTIVATION AND CO-CONTRACTION AFTER ANTERIOR CRUCIATE LIGAMENT INJURY.

BACKGROUND: Performing physical activities on compliant surfaces alters joints kinematics by decreasing joint motions. However, the effect of administering a training program on a compliant surface on muscle activities after anterior cruciate ligament (ACL) injury is unknown. HYPOTHESIS/PURPOSE: To compare the effects of training on a compliant surface and manual perturbation training on individual muscle activation and muscle co-contraction indexes after an ACL injury. It was hypothesized that patients who received training on the compliant surface would demonstrate higher individual and combined muscle activities compared to the manual group. METHOD: Sixteen patients (participated in level I/II sports) who sustained an ACL injury and had not undergone reconstructive surgery participated in this preliminary study. Eight patients received training on a compliant surface (Compliant group) and data of eight patients matched by age and sex from a previous study who received manual perturbation training were used as a control group (Manual group). Patients in both groups completed standard three-dimensional gait motion analysis with surface electromyography (EMG) of several lower extremity muscles during gait. Muscle co-contraction index and individual muscle activations were computed during weight acceptance (WA) and mid-stance (MS) intervals. A 2x2 analysis of variance (ANOVA) was used with an alpha level of p<0.10 to account for the high EMG variability. RESULTS: The compliant group significantly increased muscle co-contraction of vastus lateralis-lateral hamstring (VL-LH), vastus medialis-gastrocnemius medialis (VM-MG), and vastus lateralis (VL) muscle activity during WA (p ≤ 0.035) and manual group significantly decreased VM-MG muscle co-contraction during WA (p=0.099) after training. CONCLUSION: Administering training on a compliant surface provides different effects on muscle activation compared to manual perturbation training after an ACL injury. Training on a compliant surface caused increased muscle co-contraction indexes and individual muscle activation, while manual perturbation training decreased the VM-MG muscle co-contraction index. LEVEL OF EVIDENCE: 2b.

Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study.

BACKGROUND: Some athletes demonstrate excellent dynamic stability after anterior cruciate ligament (ACL) rupture and return to sport without ACL reconstruction (ACLR) (copers). Others demonstrate persistent instability despite rehabilitation (noncopers) and require surgical stabilization. Testing to determine coper classification can identify potential copers early after rupture. It is unclear how coper classification changes after a brief intervention and how early classification relates to long-term outcomes. PURPOSE: (1) To evaluate the consistency of early coper classification (potential coper vs noncoper) before and after progressive neuromuscular and strength training (NMST) among athletes early after acute ACL rupture and (2) to evaluate the association of early coper classification with 2-year success after ACL rupture. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This was a prospective analysis from the Delaware-Oslo ACL Cohort Study, composed of athletes consecutively enrolled early after ACL rupture. Participants (n = 271) were tested and classified as potential copers or noncopers according to established criteria before and after a 10-session NMST program. Success 2 years after ACLR or nonoperative rehabilitation was defined as meeting or exceeding sex- and age-matched norms for knee function, no ACL graft rupture, and ≤1 episode of giving way within the previous year. The McNemar test evaluated changes in coper classification pre- to posttraining. Logistic regression adjusted for baseline characteristics was used to evaluate the association of early coper classification and surgical status with 2-year success. RESULTS: Of 300 athletes enrolled, 271 (90%) completed the posttraining data collection, and 219 (73%) returned for the 2-year follow-up. The coper classifications were different between time points: nearly half of those classified initially as noncopers became potential copers ( P < .001). At the 2-year follow-up, 66% of the ACLR group and 74% of the nonoperative group were successful. Athletes who were potential copers posttraining and chose ACLR or nonoperative rehabilitation had 2.7 (95% CI, 1.3-5.6) and 2.9 (95% CI, 1.2-7.2) times the odds of success, respectively, as compared with noncopers who chose ACLR. CONCLUSION: Coper classification improved after NMST; more athletes became potential copers. Athletes who were potential copers after NMST were more likely to succeed 2 years later regardless of whether they had surgery, strongly supporting the addition of NMST before ACLR. Persistent noncopers fared poorly, indicating that more intensive rehabilitation may be needed.

Patellofemoral Pain.

Patellofemoral pain (PFP) is a common musculoskeletal-related condition that is characterized by insidious onset of poorly defined pain, localized to the anterior retropatellar and/or peripatellar region of the knee. The onset of symptoms can be slow or acutely develop with a worsening of pain accompanying lower-limb loading activities (eg, squatting, prolonged sitting, ascending/descending stairs, jumping, or running). Symptoms can restrict participation in physical activity, sports, and work, as well as recur and persist for years. This clinical practice guideline will allow physical therapists and other rehabilitation specialists to stay up to date with evolving PFP knowledge and practices, and help them to make evidence-based treatment decisions. J Orthop Sports Phys Ther. 2019;49(9):CPG1-CPG95. doi:10.2519/jospt.2019.0302.

INFLUENCE OF PATIENT DEMOGRAPHICS AND GRAFT TYPES ON ACL SECOND INJURY RATES IN IPSILATERAL VERSUS CONTRALATERAL KNEES: A SYSTEMATIC REVIEW AND META-ANALYSIS.

BACKGROUND: There are inconsistencies in the reported rates of second anterior cruciate ligament (ACL) injuries per limb, patients' sex and graft types after primary ACL reconstruction (ACLR). There are also inconsistencies regarding the influence of these factors on the occurrence of second ACL injury after primary ACLR. PURPOSE: To determine the rate of second ACL injury, to either the ipsilateral graft or contralateral healthy ACL, as influenced by sex, age, and graft types and to determine the influence of sex, age, and graft types on the occurrence of second ACL injury after primary ACLR. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A computerized search of MEDLINE, CINAHL, and SPORTDiscus was conducted using combinations of these terms: ACL, ACLR, re-injury, re-rupture, revisions, contralateral tear, ipsilateral graft tear, and second injury. Articles were required to report the number or percentage of sex, graft type, ipsilateral graft and contralateral ACL injuries after ACLR. Rates of second ACL injuries and pooled dichotomous data were calculated using random-effect proportion meta-analysis. RESULTS: The pooled rate of second ACL injuries (ipsilateral graft and contralateral ACL) was 6.11%. A slightly higher rate of ipsilateral graft injuries (3.29%) than contralateral ACL injuries (2.82%) (OR: 1.09 [95%CI: 0.89, 1.34] was reported. Ipsilateral graft injuries occurred earlier (median: 20 months) than contralateral ACL injuries (median: 36.3 months). Men had lower rate of second ACL injuries (5.67%) than women (6.84%) (OR: 0.92 [95%CI: 0.70, 1.20]). Significantly higher rate of ipsilateral graft injuries (3.40%) occurred in men compared to contralateral ACL injuries (2.26%) (OR: 1.53 [95CI%: 1.33, 1.77]), while women had significantly higher rate of contralateral ACL injuries (3.75%) compared to ipsilateral graft injuries (3.09%) (OR: 0.73 [95%CI: 0.55, 0.96]). The rate of second ACL (ipsilateral graft and contralateral ACL) injuries was higher in patients with hamstring tendon (HT) autograft (5.83%) than bone-patella tendon-bone autograft (BPTB) (5.10%) (p = 0.04) and allografts (3.12%) (p<0.0001). The rate of ipsilateral graft injuries was significantly higher than contralateral ACL injuries in all graft types (p<0.001). CONCLUSION: Injuries to the ipsilateral graft are more common than contralateral ACL, with ipsilateral graft injuries occurring nearly 16 months earlier after ACLR. More women sustain second ACL injuries compared to men, with men incurring more injuries to the ipsilateral graft and women to the contralateral ACL. Furthermore, second ACL injuries are more common in patients with HT autograft, BPTB autograft, and then allograft; with ipsilateral graft injuries higher than contralateral ACL injuries regardless of graft types. LEVELS OF EVIDENCE: 2a.

No difference between mechanical perturbation training with compliant surface and manual perturbation training on knee functional performance after ACL rupture.

Manual perturbation training improves dynamic knee stability and functional performance after anterior cruciate ligament rupture (ACL-rupture). However, it is limited to static standing position and does not allow time-specific perturbations at different phase of functional activities. The purpose of this study was to investigate whether administering mechanical perturbation training including compliant surface provides effects similar to manual perturbation training on knee functional measures after an acute ACL-rupture. Sixteen level I/II athletes with ACL-ruptures participated in this preliminary study. Eight patients received mechanical (Mechanical) and eight subjects received manual perturbation training (Manual). All patients completed a functional testing (isometric quadriceps strength, single-legged hop tests) and patient-reported measures (Knee Outcome Survey-Activities of Daily Living Scale (KOS-ADLS), Global Rating Score (GRS), International Knee Documentation Committee 2000 (IKDC 2000) at pre- and post-training. 2 × 2 ANOVA was used for data analysis. No significant group-by-time interactions were found for all measures (p > 0.18). Main effects of time were found for single hop (Pre-testing: 85.14% ± 21.07; Post-testing: 92.49% ± 17.55), triple hop (Pre-testing: 84.64% ± 14.17; Post-testing: 96.64% ± 11.14), KOS-ADLS (Pre-testing: 81.13% ± 11.12; Post-testing: 88.63% ± 12.63), GRS (Pre-testing: 68.63% ± 15.73; Post-testing: 78.81% ± 13.85), and IKDC 2000 (Pre-testing: 66.66% ± 9.85; Post-testing: 76.05% ± 14.62) (p < 0.032). Administering mechanical perturbation training using compliant surfaces induce effects similar to manual perturbation training on knee functional performance after acute ACL-rupture. The clinical significance is both modes of training improve patients' functional-performance and limb-to-limb movement symmetry, and enhancing the patients' self-reported of knee functional measures after ACL rupture. Mechanical perturbation that provides a compliant surface might be utilized as part of the ACL rehabilitation training. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1391-1397, 2018.