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Key Objective Measurements and Outcomes for Rehabilitation Success: Testing and Decision-Making

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Knee Arthroscopy and Knee Preservation Surgery

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Abstract

With anterior cruciate ligament injuries as prevalent as they are in sport, understanding the healing behind reconstruction and repair and how to return athletes to activity is extremely important to keep them safe. Having defined goals and markers to assess whether an individual is ready to return is becoming imperative to their well-being and yet is still a topic of varying thoughts. In order to provide optimal guidance during rehabilitation, it is important for all healthcare professionals to understand the current knowledge regarding biologic healing, psychological preparedness, functional readiness, strength testing, and risk factors involved in returning the athlete to play in a safe and timely fashion. In this chapter we analyze those factors along with where they were developed and how athletes can return at a level that allows them to play, minimizes risk, and increases the chances of longevity in sport.

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References

  1. Buller LT, Best MJ, Baraga MG, Kaplan LD. Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med. 2015;3(1):2325967114563664.

    Article  PubMed  Google Scholar 

  2. Kaplan Y, Witvrouw E. When is it safe to return to sport after ACL reconstruction? Reviewing the Criteria. Sports Health. 2019;11(4):301–5.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Agel J, Rockwood T, Klossner D. Collegiate ACL injury rates across 15 sports: National Collegiate Athletic Association Injury Surveillance System Data Update (2004–2005 through 2012–2013). Clin J Sport Med. 2016;26(6):518–23.

    Article  PubMed  Google Scholar 

  4. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Bach BR Jr. Return to play following anterior cruciate ligament reconstruction. J Am Acad Orthop Surg. 2015;23(5):283–96.

    Article  PubMed  Google Scholar 

  5. Ardern CL, Glasgow P, Schneiders A, et al. 2016 consensus statement on return to sport from the first world congress in sports physical therapy, Bern. Br J Sports Med. 2016;50(14):853–64.

    Article  PubMed  Google Scholar 

  6. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596–606.

    Article  PubMed  Google Scholar 

  7. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med. 2016;50(15):946–51.

    Article  PubMed  Google Scholar 

  8. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804–8.

    Article  PubMed  Google Scholar 

  9. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543–52.

    Article  PubMed  Google Scholar 

  10. Meredith SJ, Rauer T, Chmielewski TL, et al. Return to sport after anterior cruciate ligament injury: panther symposium ACL injury return to sport consensus group. Orthop J Sports Med. 2020;8(6):2325967120930829.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Abrams GD, Harris JD, Gupta AK, et al. Functional performance testing after anterior cruciate ligament reconstruction: a systematic review. Orthop J Sports Med. 2014;2(1):2325967113518305.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Gokeler A, Welling W, Zaffagnini S, Seil R, Padua D. Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;25(1):192–9.

    Article  PubMed  Google Scholar 

  13. Hildebrandt C, Müller L, Zisch B, Huber R, Fink C, Raschner C. Functional assessments for decision-making regarding return to sports following ACL reconstruction. Part I: development of a new test battery. Knee Surg Sports Traumatol Arthrosc. 2015;23(5):1273–81.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Myer GD, Bates NA, DiCesare CA, et al. Reliability of 3-dimensional measures of single-leg drop landing across 3 institutions: implications for multicenter research for secondary ACL-injury prevention. J Sport Rehabil. 2015;24(2):198–209.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Ardern CL, Taylor NF, Feller JA, Whitehead TS, Webster KE. Psychological responses matter in returning to preinjury level of sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2013;41(7):1549–58.

    Article  PubMed  Google Scholar 

  16. Webster KE, Feller JA. Development and validation of a short version of the anterior cruciate ligament return to sport after injury (ACL-RSI) scale. Orthop J Sports Med. 2018;6(4):2325967118763763.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Webster KE, Feller JA, Lambros C. Development and preliminary validation of a scale to measure the psychological impact of returning to sport following anterior cruciate ligament reconstruction surgery. Phys Ther Sport. 2008;9(1):9–15.

    Article  PubMed  Google Scholar 

  18. Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors associated with psychological readiness to return to sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med. 2018;46(7):1545–50.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Muller B, Bowman KF Jr, Bedi A. ACL graft healing and biologics. Clin Sports Med. 2013;32(1):93–109.

    Article  PubMed  Google Scholar 

  20. Scheffler SU, Unterhauser FN, Weiler A. Graft remodeling and ligamentization after cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2008;16:834–42.

    Article  CAS  PubMed  Google Scholar 

  21. Hjorthaug GA, Madsen JE, Nordsletten L, Reinholt FP, Steen H, Dimmen S. Tendon to bone tunnel healing – a study on the time-dependent changes in biomechanics, bone remodeling, and histology in a rat model. J Orthop Res. 2015;33(2):216–23.

    Article  PubMed  Google Scholar 

  22. Killian ML, Cavinatto L, Galatz LM, Thomopoulos S. The role of mechanobiology in tendon healing. J Shoulder Elb Surg. 2012;21(2):228–37.

    Article  Google Scholar 

  23. Roy J, Mokhtar AH, Abdul Karim S, Ayathupady MS. Cognitive appraisals and lived experiences during injury rehabilitation: a narrative account within personal and situational backdrop. Asian J Sports Med. 2015;6(3):e24039.

    Article  PubMed  PubMed Central  Google Scholar 

  24. American College of Sports Medicine, American Academy of family physicians, American Academy of Orthopaedic surgeons, American medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American osteopathic academy of sports medicine. Psychological issues related to injury in athletes and the team physician: a consensus statement. Med Sci Sports Exerc. 2006;38(11):2030–4.

    Article  Google Scholar 

  25. Glazer DD. Development and preliminary validation of the injury-psychological readiness to return to sport (I-PRRS) scale. J Athl Train. 2009;44(2):185–9.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Erickson LN, Jacobs CA, Johnson DL, Ireland ML, Noehren B. Psychosocial factors 3-months after anterior cruciate ligament reconstruction predict 6-month subjective and objective knee outcomes. J Orthop Res. 2022;40(1):231–8.

    Article  PubMed  Google Scholar 

  27. Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-reported fear predicts functional performance and second ACL injury after ACL reconstruction and return to sport: a pilot study. Sports Health. 2018;10(3):228–33.

    Article  PubMed  Google Scholar 

  28. Fitzgerald G, Axe M, Snyder-Mackler L. A decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. Knee Surg Sports Traumatol Arthrosc. 2000;8(2):76–81.

    Article  CAS  PubMed  Google Scholar 

  29. Nawasreh Z, Logerstedt D, Cummer K, Axe MJ, Risberg MA, Snyder-Mackler L. Do patients failing return-to-activity criteria at 6 months after anterior cruciate ligament reconstruction continue demonstrating deficits at 2 years? Am J Sports Med. 2017;45(5):1037–48.

    Article  PubMed  Google Scholar 

  30. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2017;47(5):334–8.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Almeida GPL, Albano TR, Melo AKP. Hand-held dynamometer identifies asymmetries in torque of the quadriceps muscle after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2494–501.

    Article  PubMed  Google Scholar 

  32. Thorborg K, Bandholm T, Hölmich P. Hip- and knee-strength assessments using a hand-held dynamometer with external belt-fixation are inter-tester reliable. Knee Surg Sports Traumatol Arthrosc. 2013;21(3):550–5.

    Article  PubMed  Google Scholar 

  33. Krishnan C, Williams GN. Effect of knee joint angle on side-to-side strength ratios. J Strength Cond Res. 2014;28(10):2981–7.

    Article  PubMed  Google Scholar 

  34. Kabacinski J, Szozda PM, Mackala K, et al. Relationship between isokinetic knee strength and speed, agility, and explosive power in elite soccer players. Int J Environ Res Public Health. 2022;19(2) https://doi.org/10.3390/ijerph19020671.

  35. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review. PM R. 2011;3(5):472–9.

    Article  PubMed  Google Scholar 

  36. Habets B, Staal JB, Tijssen M, van Cingel R. Intrarater reliability of the Humac NORM isokinetic dynamometer for strength measurements of the knee and shoulder muscles. BMC Res Notes. 2018;11(1):15.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Hill AV. The maximum work and mechanical efficiency of human muscles, and their most economical speed. J Physiol. 1922;56(1–2):19–41.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. van Melick N, van der Weegen W, van der Horst N. Quadriceps and hamstrings strength reference values for athletes with and without anterior cruciate ligament reconstruction who play popular pivoting sports, including soccer, basketball, and handball: a scoping review. J Orthop Sports Phys Ther. 2022;52(3):142–55.

    Article  PubMed  Google Scholar 

  39. Clagg S, Paterno MV, Hewett TE, Schmitt LC. Performance on the modified star excursion balance test at the time of return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2015;45(6):444–52.

    Article  PubMed  Google Scholar 

  40. van Melick N, van Rijn L, Nijhuis-van der Sanden MWG, Hoogeboom TJ, van Cingel REH. Fatigue affects quality of movement more in ACL-reconstructed soccer players than in healthy soccer players. Knee Surg Sports Traumatol Arthrosc. 2019;27(2):549–55.

    Article  PubMed  Google Scholar 

  41. Thomee R, Neeter C, Gustavsson A, et al. Variability in leg muscle power and hop performanceafter anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2012;20:1143–51.

    Article  PubMed  Google Scholar 

  42. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19(5):513–8.

    Article  CAS  PubMed  Google Scholar 

  43. Gustavsson A, Neeter C, Thomeé P, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778–88.

    Article  PubMed  Google Scholar 

  44. Xergia SA, Pappas E, Georgoulis AD. Association of the Single-Limb hop Test with Isokinetic, kinematic, and kinetic asymmetries in patients after anterior cruciate ligament reconstruction. Sports Health. 2015;7(3):217–23.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Neeter C, Gustavsson A, Thomeé P, Augustsson J, Thomeé R, Karlsson J. Development of a strength test battery for evaluating leg muscle power after anterior cruciate ligament injury and reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(6):571–80.

    Article  PubMed  Google Scholar 

  46. Barber SD, Noyes FR, Mangine RE, McCloskey JW, Hartman W. Quantitative assessment of functional limitations in normal and anterior cruciate ligament-deficient knees. Clin Orthop Relat Res. 1990;255:204–14.

    Article  Google Scholar 

  47. Stiffler MR, Sanfilippo JL, Brooks MA, Heiderscheit BC. Star excursion balance test performance varies by sport in healthy division I collegiate athletes. J Orthop Sports Phys Ther. 2015;45(10):772–80.

    Article  PubMed  Google Scholar 

  48. Kotsifaki A, Korakakis V, Graham-Smith P, Sideris V, Whiteley R. Vertical and Horizontal Hop Performance: Contributions of the Hip, Knee, and Ankle. Sports Health. Published online February 9, 2021:1941738120976363.

    Google Scholar 

  49. Oberländer KD, Brüggemann GP, Höher J, Karamanidis K. Altered landing mechanics in ACL-reconstructed patients. Med Sci Sports Exerc. 2013;45(3):506–13.

    Article  PubMed  Google Scholar 

  50. Kotsifaki A, Korakakis V, Whiteley R, Van Rossom S, Jonkers I. Measuring only hop distance during single leg hop testing is insufficient to detect deficits in knee function after ACL reconstruction: a systematic review and meta-analysis. Br J Sports Med. Published online May 29, 2019:bjsports-2018-099918.

    Google Scholar 

  51. Hunnicutt JL, Xerogeanes JW, Tsai LC, et al. Terminal knee extension deficit and female sex predict poorer quadriceps strength following ACL reconstruction using all-soft tissue quadriceps tendon autografts. Knee Surg Sports Traumatol Arthrosc. 2021;29(9):3085–95.

    Article  PubMed  Google Scholar 

  52. Welling W, Benjaminse A, Lemmink K, Dingenen B, Gokeler A. Progressive strength training restores quadriceps and hamstring muscle strength within 7 months after ACL reconstruction in amateur male soccer players. Phys Ther Sport. 2019;40:10–8.

    Article  PubMed  Google Scholar 

  53. Myers BA, Jenkins WL, Killian C, Rundquist P. Normative data for hop tests in high school and collegiate basketball and soccer players. Int J Sports Phys Ther. 2014;9(5):596–603.

    PubMed  PubMed Central  Google Scholar 

  54. Castagna C, Castellini E. Vertical jump performance in Italian male and female national team soccer players. J Strength Cond Res. 2013;27(4):1156–61.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. The Steadman Clinic, Vail, CO, USA

    Tyler Zajac

  2. Naval Health Clinic Annapolis, Annapolis, MD, USA

    Robert Waltz

  3. Vail Health, Howard Head Sports Medicine, Vail, CO, USA

    Paul Westgard

Authors
  1. Tyler Zajac
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  2. Robert Waltz
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  3. Paul Westgard
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Corresponding author

Correspondence to Paul Westgard .

Editor information

Editors and Affiliations

  1. Sports Medicine Clinic, Stanford University, Redwood City, CA, USA

    Seth L. Sherman

  2. Midwest Orthopedics, Rush University, Chicago, IL, USA

    Jorge Chahla

  3. Department of Orthopedics, Hospital for Special Surgery, New York, NY, USA

    Scott A. Rodeo

  4. Complex Knee and Sports Medicine Surgeon, Twin Cities Spine Center, Edina, MN, USA

    Robert LaPrade

Section Editor information

  1. Owens Recovery Science, INC, San Antonio, Texas, USA

    Johnny Owens

  2. Orthopaedic and Sports Physical Therapy, Stanford Healthcare, Redwood City, USA

    Bill Seringer

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Zajac, T., Waltz, R., Westgard, P. (2023). Key Objective Measurements and Outcomes for Rehabilitation Success: Testing and Decision-Making. In: Sherman, S.L., Chahla, J., Rodeo, S.A., LaPrade, R. (eds) Knee Arthroscopy and Knee Preservation Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-82869-1_73-1

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  • DOI: https://doi.org/10.1007/978-3-030-82869-1_73-1

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-82869-1

  • Online ISBN: 978-3-030-82869-1

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