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Background: Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist. Purpose: (1) To identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation. Study Design: Cohort study; Level of evidence, 3. Methods: We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation. Results: Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory. Conclusion: We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories’ validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

Objective The objective of this study was to examine the association of quadriceps strength symmetry and surgical status (ACL reconstruction or nonoperative management) with early clinical knee OA 5 years after ACL injury or reconstruction. Methods 204/300 athletes were analyzed 5 years after ACL injury or reconstruction (ACLR). Quadriceps strength was measured and reported as a limb symmetry index. We identified participants with early clinical knee OA using criteria that two of four Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales score ≤85% (Luyten et al. 2018). We calculated odds ratios (OR) and 95% confidence intervals (CI) using logistic regression, adjusted for age, sex, meniscal injury, and BMI, to examine the associations between quadriceps strength and surgical status with clinical knee OA. Results 21% of participants met KOOS criteria for clinical knee OA (Luyten et al. 2018). For every 1% increase in quadriceps limb symmetry index, there was 4% lower odds of clinical OA (adjusted OR 0.96, 95% CI 0.93-0.99) at 5 years. Surgical status was not associated with clinical knee OA (adjusted OR 0.58, 95% CI 0.23, 1.50). Conclusions More symmetrical quadriceps strength, but not surgical status, 5 years after ACL injury or reconstruction was associated with lower odds of clinical knee OA.

ObjectivesTo investigate the proportion of patients that pass a return to sport (RTS) test battery and assess changes in patient-reported outcomes and lower extremity muscle strength following three months of exericse-based rehabilitation in non-surgically treated patients with anterior cruciate ligament (ACL) injury.DesignProspective cohort study.SettingClinical environment (public municipal).ParticipantsThirty-nine ACL injured patients (54% female, median age (IQR) 28 years (24–35).Main outcome measuresThe Knee Injury and Osteoarthritis Outcome Score, Knee Outcome Survey Activities of Daily Living Scale, single hop for distance, crossover hop for distance, side hop test, the Agility T-test, and quadriceps and hamstrings isometric maximal voluntary contraction (MVC).ResultsFollowing 3 months of rehabilitation, patients had statistically significant improvements in all patients-reported outcomes and in quadriceps and hamstring MVC. Of 28 patients who completed all RTS tests, 11% passed six RTS criteria, 14% five criteria, 11% four criteria, 4% three criteria, 18% two criteria, 21% one criterion, and 21% none of the criteria.ConclusionsThe results suggest that three months of public municipal rehabilitation improves patient-reported outcomes and lower extremity muscle strength in non-surgically treated patients with ACL injury. However, only one in every 10 patients passed all RTS criteria.

Background Anterior cruciate ligament (ACL) injuries can be treated with or without ACL reconstruction (ACLR), and more high-quality studies evaluating outcomes after the different treatment courses are needed. The purpose of the present study was to describe and compare 5-year clinical, functional, and physical activity outcomes for patients who followed our decision-making and treatment algorithm and chose (1) early ACLR with preoperative and postoperative rehabilitation, (2) delayed ACLR with preoperative and postoperative rehabilitation, or (3) progressive rehabilitation alone. Early ACLR was defined as that performed ≤6 months after the preoperative rehabilitation program, and late ACLR was defined as that performed >6 months after the preoperative rehabilitation program. Methods We included 276 patients from a prospective cohort study. The patients had been active in jumping, pivoting, and cutting sports before the injury and sustained a unilateral ACL injury without substantial concomitant knee injuries. The patients chose their treatment through a shared decision-making process. At 5 years, we assessed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, sports participation, quadriceps muscle strength, single-legged hop performance, and new ipsilateral and contralateral knee injuries. Results The 5-year follow-up rate was 80%. At 5 years, 64% of the patients had undergone early ACLR, 11% had undergone delayed ACLR, and 25% had had progressive rehabilitation alone. Understandably, the choices that participants made differed by age, concomitant injuries, symptoms, and predominantly level-I versus level-II preinjury activity level. There were no significant differences in any clinical, functional, or physical activity outcomes among the treatment groups. Across treatment groups, 95% to 100% of patients were still active in some kind of sports and 65% to 88% had IKDC-SKF and KOOS scores above the threshold for a patient acceptable symptom state. Conclusions Patients with ACL injury who were active in jumping, pivoting, and cutting sports prior to injury; who had no substantial concomitant knee injuries; and who followed our decision-making and treatment algorithm had good 5-year knee function and high sport participation rates. Three of 4 patients had undergone ACLR within 5 years. There were no significant differences in any outcomes among patients treated with early ACLR, delayed ACLR, or progressive rehabilitation alone. Level of evidence Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objectives (1) To assess prognostic factors for patient-reported outcome measures (PROMs) and physical activity 2 to 10 years after anterior cruciate ligament reconstruction (ACLR) or anterior cruc...

ObjectiveTo investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction.DesignPrognosis systematic review (PROSPERO registration number CRD42016036788).MethodsWe searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology.ResultsOf 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%–21% when follow-up was ConclusionNew meniscal tears occurred in 0%–52% of patients between 4 months and 20 years (mean 4.9±4.4 years) following treatment for ACL injury. The certainty of evidence was too low to guide surgical treatment decisions. This review cannot conclude that the incidence of new meniscal tears is lower if ACL injury is treated with surgery compared with treatment with rehabilitation only.

To (1) describe which strength training exercise descriptors are reported in anterior cruciate ligament reconstruction (ACLR) rehabilitation research, and (2) compare the current standards of reporting ACLR strength training exercise descriptors to international best-practice strength training guidelines.Scoping review.We searched the MEDLINE, PsycINFO, CINAHL, SPORTDiscus, Academic Search, ERIC, Health Source: Nursing, Health Source: Consumer, MasterFILE, and Africa-Wide Information databases.We included level I to IV studies of ACLR rehabilitation programs with 1 or more reported strength training exercise descriptors. We used a predefined list of 19 exercise descriptors, based on the American College of Sports Medicine (ACSM) exercise recommendations, the Consensus on Exercise Reporting Template (CERT), and the Toigo and Boutellier exercise descriptor framework.Completeness and the standard of reporting exercise descriptors in ACLR rehabilitation programs were assessed by means of international best-practice strength training standards.We extracted data on 117 exercises from 41 studies. A median of 7 of the 19 possible exercise descriptors were reported (range, 3-16). Reporting of specific exercise descriptors varied across studies, from 95% (name of the strength training exercise) to 5% (exercise aim, exercise order). On average, 46%, 35%, and 43% of the exercise descriptors included in the ACSM, CERT, and Toigo and Boutellier guidelines were reported, respectively.Key exercise descriptors for muscle strength gains are not reported in studies on ACLR rehabilitation. Only the exercise name, number of exercises, frequency, and experimental period were reported in most of the studies.

Classification algorithms determine the similarity of an observation to defined classes, e.g., injured or healthy athletes, and can highlight treatment targets or assess progress of a treatment. The primary aim was to cross-validate a previously developed classification algorithm using a different sample, while a secondary aim was to examine its ability to predict future ACL injuries. The examined outcome measure was 'healthy-limb' class membership probability, which was compared between a cohort of athletes without previous or future (No Injury) previous (PACL) and future ACL injury (FACL). The No Injury group had significantly higher probabilities than the PACL (p < 0.001; medium effect) and FACL group (p ≤ 0.045; small effect). The ability to predict group membership was poor for the PACL (area under curve [AUC]; 0.61

Objectives: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. Design: Prospective cohort. Participants: 43 nonprofessional pivoting sport athletes with ACLR. Main outcome: Clinician-and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). Results: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1-1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). Conclusion: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk. (c) 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Funding Agencies|Swedish Research Council for Sport Science; International Olympic Committee; Norwegian Fund for Post-Graduate Training in Physiotherapy

Many athletes push themselves beyond their limits and sacrifice short-term well-being and long-term health for a chance at victory. Elite sport shapes a certain type of character: mentally and physically tough, and unrelenting in the pursuit of the marginal gains that separate champions from the second best. The difficult question, especially for elite sports, is, "How do managers, coaches, athletes, and members of the health team find the balance between protecting the athlete's health and pursuing athletic greatness?" In this Viewpoint, we offer 4 perspectives on the roles and responsibilities of sports physical therapists: (1) the care of, and ethical obligations to, the elite athlete, (2) decision making that is in the athlete's best interest, (3) building a working relationship with the athlete, and (4) supporting athletes who face end-of-career decisions.

Background: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. Purpose: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. Study Design: Case series; Level of evidence, 4. Methods: Forty-six children aged Results: At a mean 8 years of follow-up, 24 patients (55%) had undergone ACL reconstruction, and 16 (36%) had undergone meniscal surgery. Quadriceps muscle strength symmetry was >90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. Conclusion: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery.

ObjectiveTo elucidate the relationships between age, return to level I sport (RTS) within the first postoperative year, passing RTS criteria and second anterior cruciate ligament (ACL) injury.MethodsIn a prospective cohort study, 213 athletes were followed for 2 years after ACL reconstruction to record second ACL injuries. Independent variables were age, passing RTS criteria and level I RTS within the first postoperative year (vs later or no RTS). We defined passing RTS criteria as ≥90 on the Knee Outcome Survey — Activities of Daily Living Scale, global rating scale of function and quadriceps strength/hop test symmetry.ResultsThe follow-up rate was >87% for all outcomes. In multivariable analysis, level I RTS within the first postoperative year and passing RTS criteria were highly associated with second ACL injury (level I RTS HR: 6.0 (95% CI: 1.6 to 22.6), pass RTS criteria HR: 0.08 (95% CI: 0.01 to 0.6)), while age was not (age HR: 0.96 (95% CI: 0.89 to 1.04)). Athletes ConclusionHigh rates of second ACL injury in young athletes may be driven by a mismatch between RTS rates and functional readiness to RTS. Passing RTS criteria was independently associated with a lower second ACL rate. Allowing more time prior to RTS, and improving rehabilitation and RTS support, may reduce second ACL injury rates in young athletes with ACL reconstruction.

IOC In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/ guardians make the best possible decisions. Linkoping Univ, Div Physiotherapy, Linkoping, Sweden La Trobe Univ, Sch Allied Hlth, Melbourne, Vic 3086, Australia Oslo Univ Hosp, Div Orthopaed Surg, Oslo, Norway Norwegian Sch Sport Sci, OSTRC, Oslo, Norway Univ Oslo, Inst Clin Med, Oslo, Norway Norwegian Sch Sport Sci, Dept Sports Med, Oslo, Norway Tennessee Orthopaed Alliance, Nashville, TN USA Hop Femme Mere Enfant, Dept Pediat Orthopaed Surg, Lyon, France Univ Fed Sao Paulo, Orthoped Dept, Sao Paulo, Brazil Karolinska Inst, Stockholm Sports Trauma Res Ctr, Stockholm, Sweden Childrens Hosp Philadelphia, Dept Orthopaed, Philadelphia, PA 19104 USA Epworth Healthcare, OrthoSport Victoria Res Unit, Melbourne, Vic, Australia La Trobe Univ, Coll Sci Hlth & Engn, Melbourne, Vic, Australia Univ Gothenburg, Dept Orthopaed, Sahlgrenska Acad, Gothenburg, Sweden Boston Childrens Hosp, Div Sports Med, Boston, MA USA Harvard Med Sch, Boston, MA USA Steadman Philippon Res Inst, Vail, CO USA Steadman Clin, Vail, CO USA Swansea Univ, Coll Engn, Swansea, W Glam, Wales Santa Monica Orthopaed & Sports Med Grp, Los Angeles, CA USA Micheli Ctr Sports Injury Prevent, Waltham, MA USA Univ Calgary, Sports Med Ctr, Calgary, AB, Canada Univ Chicago, Dept Orthopaed & Rehabil Med, Chicago, IL 60637 USA North Sydney Orthopaed & Sports Med Ctr, Sydney, NSW, Australia Ctr Hosp Luxembourg, Dept Orthopaed Surg, Luxembourg, Luxembourg Luxembourg Inst Hlth, Sports Med Res Lab, Luxembourg, Luxembourg Ruprecht Karls Univ Heidelberg, Inst Anat & Cell Biol, Heidelberg, Germany ATOS Klin, HKF Int Ctr Hip Knee Foot Surg & Sports Traumat, Heidelberg, Germany FIFA Med Ctr Excellence Veloc Phys Therapy, Los Angeles, CA USA Int Olymp Comm, Med & Sci Dept, Lausanne, Switzerland Univ Calgary, Fac Kinesiol, Sport Injury Prevent Res Ctr, Calgary, AB, Canada Univ Ghent, Fac Med & Hlth Sci, Dept Rehabil Sci & Physiotherapy, Ghent, Belgium Univ Fed Sao Paulo, Orthoped Dept, Sao Paulo, Brazil Web of Science

Clinicians rely on rigorous systematic reviews to guide practice. We therefore suspect many clinicians will note the results of the 2019 systematic review and meta-analysis by Webster and Hewett, ‘What is the Evidence for and Validity of Return-to-Sport Testing after Anterior Cruciate Ligament Reconstruction Surgery? A Systematic Review and Meta-Analysis’.1 We agree that it is important to evaluate the association between return-to-sport (RTS) test batteries and outcomes after ACL reconstruction. The third review question in Webster and Hewett (2019) is particularly pertinent: ‘Is passing RTS test batteries associated with reduced rates of subsequent knee injury (all knee injuries and ACL injury)?’1 We are authors of several of the original data papers cited in the systematic review, and we are concerned about the study methodology and its conclusions. We highlight major problems with including two studies and present revised analyses that demonstrate the impact these studies had on the conclusions. First, we question the validity of pooling studies with substantial clinical and methodological diversity.2 The meta-analysis combined studies where only some athletes returned to sport3 4 and studies where all, or mostly all, returned to sport;5–7 studies with skeletally immature patients7 and studies with elite athletes;6 and studies where substantially different RTS test batteries were used. Our second concern is that Webster and Hewett1 did not assess risk of bias, a fundamental precept of systematic review methodology clearly stated in the PRISMA reporting guideline.8–10 Assessment of study quality (as performed by Webster and Hewett1) does not quantify risk of bias.11 A risk of bias assessment identifies factors within studies that can skew results, and these factors must be considered carefully in the decision to pool data and in the conclusion. Important bias domains for review questions 2 and 3 include …

Background: The rate of secondary knee injuries after pediatric anterior cruciate ligament (ACL) injury is uncertain, and previous studies are limited because of poor methodology. Purpose: To evaluate the incidence of new meniscal injuries since the initial diagnostic magnetic resonance imaging (MRI) of young adults who sustained a pediatric ACL injury. In addition, to evaluate meniscal and cartilage injuries in the index knee and contralateral knee injuries on MRI at final follow-up (9.5 years). Furthermore, to assess leg length and alignment based on long-leg radiographs. Study Design: Case series; Level of evidence, 4. Methods: Study population at final follow-up included 47 young adults who sustained a pediatric ACL injury before age 13 years. They were followed prospectively since the time of injury for a mean 9.5 years at final follow-up. Imaging included diagnostic MRI of the index knee and 3.0-T MRI of both knees at 1-, 2-, and 9.5-year follow-up, in addition to long-leg radiographs at final follow-up. Forty-three patients underwent active rehabilitation without ACL reconstruction initially; 4 were treated with initial ACL reconstruction. At final follow-up, 27 (57%) had undergone ACL reconstruction. Results: Fourteen patients had meniscal tears in the index knee at final follow-up (prevalence, 30%). The majority of these were in the same location as previously repaired tears (n = 9). Between diagnostic MRI and final follow-up, 16 patients had sustained new meniscal tears to a healthy meniscus (incidence, 34%). At final follow-up, meniscal injuries recorded at baseline or during follow-up were no longer visible and appeared healed in 17 patients (20 tears). MRI at final follow-up showed cartilage injuries in the index knee of 13 patients (28%) and contralateral injuries in 8 patients (meniscus, n = 2; cartilage, n = 5; subchondral fracture, n = 1). Two patients had a leg-length difference >15 mm, and 3 had side-to-side difference in knee alignment >5°. Conclusion: The incidence of new meniscal tears after pediatric ACL injury was 34% during a mean follow-up period of 9.5 years. At final follow-up, 27 patients (57%) had normal menisci, and none had developed knee osteoarthritis. Primary active rehabilitation, close follow-up, and delayed surgery if needed may be a viable and safe treatment option for some pediatric ACL injuries.

A long track speed skater sustained a deep horizontal cut to the right knee just distally to the patella, after he got hit by the skate blade of the pair mate. The injury included a complete patellar tendon rupture from the apex of the patella, a 1 mm deep transverse cut in the femoral condyle and a partial rupture of the anterior cruciate ligament. The tendon rupture was repaired with transosseous suture repair without augmentation. A knee brace was used for 8 weeks, with a gradual decrease in flexion restraints. A rehabilitation programme was overseen by a dedicated physiotherapist. At 6 months, he started a gradual return to skating sessions. After 1 year, he had symmetrical single-legged hop performance, but quadriceps weakness due to pain. The patient returned to competition speed skating at national levels after 11 months, and within the first postoperative year, he was breaking new personal records on the ice.

Summary In October 2017, the International Olympic Committee hosted an international expert group of physiotherapists and orthopaedic surgeons who specialise in treating and researching paediatric ACL injuries. Representatives from the American Orthopaedic Society for Sports Medicine, European Paediatric Orthopaedic Society, European Society for Sports Traumatology, Knee Surgery & Arthroscopy, International Society of Arthroscopy Knee Surgery and Orthopaedic Sports Medicine, Pediatric Orthopaedic Society of North America and Sociedad Latinoamericana de Artroscopia, Rodilla y Deporte attended. Physiotherapists and orthopaedic surgeons with clinical and research experience in the field, and an ethics expert with substantial experience in the area of sports injuries also participated. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision-making with children and the potential long-term ramifications of the injury. This consensus statement addresses six fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries. The aim of this consensus statement is to provide a comprehensive, evidence-informed summary to support the clinician, and help children with ACL injury and their parents/guardians make the best possible decisions.

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.

We like to think that we are successful in the treatment of individuals with anterior cruciate ligament (ACL) injury, but recent literature reveals that only about 60% of these individuals make a full recovery, less than 60% return to sport, and more than 50% develop knee osteoarthritis (OA) by middle age. Both short- and long-term outcomes after ACL injury and reconstruction need attention and action. We need to implement strategies early after ACL injury to prevent the development and progression of posttraumatic OA, rather than "sit and wait" until posttraumatic knee OA has developed. J Orthop Sports Phys Ther 2016;46(9):710-713. doi:10.2519/jospt.2016.0608.

Introduction Intention of returning to level-I sports (handball, soccer, basketball and floorball) is one of the main reasons for choosing anterior cruciate ligament reconstruction (ACLR). Our aim was to assess participation in level-I sports at one, two and five years postoperatively in those who choose ACLR to enable return to level-I sport. A secondary aim was to assess the relationship between participation in level-I sports and self-reported knee function. Materials and methods Sixty patients who all stated they chose ACLR to return to level-I sport (55% women, median age 23 years [min-max: 14–39]) were included in a prospective cohort study. Participants had no major concomitant injuries and participated in nonprofessional competitive level-I sports ≥2 times/week prior to injury. Sports participation and International Knee Documentation Committee Subjective Knee Form (IKDC 2000)-scores was recorded one, two and five years postoperatively. Results At one, two and five years after ACLR, 29/58 (50% [95% CI: 36% to 64%]), 30/55 (55%[95% CI: 41% to 68%]) and 15/55 (27% [95% CI: 15% to 39%]) participated in level-I sports, respectively (follow-up rate: 92%–97%). Among those who participated at one year, 7/24 (29%) had quit after two years. Six of 48 (13%) participated at all three follow-ups. Participation in level-I sports was associated with higher IKDC 2000-scores one (b=11.9; 95% CI: 4.4 to 19.3) and two years (b=9.9; 95% CI: 2.3 to 17.4) postoperatively. Conclusion Patients considering undergoing ACLR to enable return to level-I sports should be informed of the modest likelihood of returning one to five years postoperatively. Very few sustain participation from one to five years. Participation in level-I sports is associated with better self-reported knee function.

Alarming underutilisation of rehabilitation after ACL reconstruction (ACLR) was highlighted in a recent study.1 These Australian trends are not unique, but support the emerging realisation that athletes may be overtreated with ACLR surgery, but undertreated when it comes to rehabilitation. We use the term undertreated to describe insufficient rehabilitation—either because athletes are discharged too soon or because the rehabilitation content is inadequate. Among non-elite athletes with ACLR, only 5% received rehabilitation1 that followed evidence-based guidelines2: ≥6 months’ rehabilitation, including agility and landing exercises, and a structured return to sport (RTS). Most athletes were undertreated: 45% (50 of 111) never saw a clinician after the third postoperative month and 70% (78 of 111) never did agility or landing exercises.1 When clinical practice does not follow evidence-based guidelines, we are not offering the best to our athletes. Outcomes following ACLR are mainly dictated by the athlete, the rehabilitation clinician and the orthopaedic surgeon. And the rehabilitation clinician might be the central player in this trifecta.1 Almost a year …

Handball players with ACL injury (whether treated surgically or non-surgically) must complete a high-quality, supervised, criterion-based rehabilitation programme with high adherence. The overarching goal of rehabilitation after ACL injury and/or surgery is to restore knee function so that the player can participate fully in all aspects of life, with an acceptable risk for reinjury and post-traumatic osteoarthritis. Rehabilitation for the handball player with ACL injury should commence as soon as possible following the injury to ensure optimal loading and facilitate tissue healing, to build the player’s confidence and motivation and to provide the best opportunity for the player to reach his or her sports participation goals. Individualised rehabilitation that emphasises the physical performance characteristics needed for successful handball performance must incorporate criterion-based progressions that also respect the time required for biological healing. Quality rehabilitation should address five key phases, with each phase building on the functional gains made in the previous phase: prehabilitation (for players having ACL reconstruction), acute phase (impairment focus), intermediate phase (dynamic knee stability focus), late phase (sport-specific focus) and injury prevention phase (manage workload focus). Managing effusion and pain throughout rehabilitation provides a helpful guide for optimal loading of the knee. It is also important to consider the overall acute and chronic workload of the player, especially before returning to training and competition. Psychological factors including motivation, reinjury anxiety and confidence may be addressed during rehabilitation using goal setting and consistent assessment and feedback.

In October 2017, the International Olympic Committee hosted an international expert group of physical therapists and orthopaedic surgeons who specialize in treating and researching pediatric anterior cruciate ligament (ACL) injuries. The purpose of this meeting was to provide a comprehensive, evidence-informed summary to support the clinician and help children with ACL injury and their parents/guardians make the best possible decisions. Representatives from the following societies attended: American Orthopaedic Society for Sports Medicine; European Paediatric Orthopaedic Society; European Society for Sports Traumatology, Knee Surgery, and Arthroscopy; International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine; Pediatric Orthopaedic Society of North America; and Sociedad Latinoamericana de Artroscopia, Rodilla, y Deporte. Physical therapists and orthopaedic surgeons with clinical and research experience in the field and an ethics expert with substantial experience in the area of sports injuries also participated. This consensus statement addresses 6 fundamental clinical questions regarding the prevention, diagnosis, and management of pediatric ACL injuries. Injury management is challenging in the current landscape of clinical uncertainty and limited scientific knowledge. Injury management decisions also occur against the backdrop of the complexity of shared decision making with children and the potential long-term ramifications of the injury. ispartof: ORTHOPAEDIC JOURNAL OF SPORTS MEDICINE vol:6 issue:3 ispartof: location:United States status: published

Anterior cruciate ligament (ACL) reconstruction is common after ACL injury, particularly in young, active individuals. ACL reconstruction does not have universally good outcomes. Not all athletes will return to sport after ACL reconstruction (ACLR), and after reconstruction these individuals are at a high risk for second ACL injury and osteoarthritis. The best evidence suggests that ACLR is not necessary for everyone. This chapter will discuss the management of athletes after acute ACL rupture. Long- and short-term outcomes of operative and nonoperative management as well as determinants of success will be discussed. Athletes can return to their prior levels of sports without ACL reconstruction with progressive rehabilitation after ACL rupture. With recent evidence that outcomes after operative and nonoperative ACL injury management do not necessarily favor surgery, the authors recommend that athletes undergo a progressive physical therapy regimen that includes strengthening and neuromuscular training after ACL injury prior to the decision to undergo ACLR. If nonoperative management is elected as progressive, a criterion-based rehabilitation program culminating in a structured return to activity progression and battery of tests to determine readiness for return to sports should be employed.

Background Preoperative knee function is associated with successful postoperative outcome after anterior cruciate ligament reconstruction (ACLR). However, there are few longer term studies of patients who underwent progressive preoperative and postoperative rehabilitation compared to usual care. Objectives To compare preoperative and 2 year postoperative patient-reported outcomes (PROs) in patients undergoing progressive preoperative and postoperative rehabilitation at a sports medicine clinic compared with usual care. Methods We included patients aged 16–40 years undergoing primary unilateral ACLR. The preoperative and 2 year postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) of 84 patients undergoing progressive preoperative and postoperative rehabilitation at a sports medicine clinic (Norwegian Research Center for Active Rehabilitation (NAR) cohort) were compared with the scores of 2690 patients from the Norwegian National Knee Ligament Registry (NKLR). The analyses were adjusted for sex, age, months from injury to surgery and cartilage/meniscus injury at ACLR. Results The NAR cohort had significantly better preoperative KOOS in all subscales, with clinically relevant differences (>10 points) observed in KOOS Pain, activities of daily living (ADL), Sports and Quality of Life. At 2 years, the NAR cohort still had significantly better KOOS with clinically relevant differences in KOOS Symptoms, Sports and Quality of Life. At 2 years, 85.7–94% of the patients in the NAR cohort scored within the normative range of the different KOOS subscales, compared to 51.4–75.8% of the patients in the NKLR. Conclusions Patients in a prospective cohort who underwent progressive preoperative and postoperative rehabilitation at a sports medicine clinic showed superior patient-reported outcomes both preoperatively and 2 years postoperatively compared to patients in the NKLR who received usual care.

Despite the vast quantity of information available to patients, parents and clinicians, high-quality information and knowledge remains in relatively short supply.1 The benefits of an active lifestyle are incontrovertible. However, youth athletes have substantial risk for sports-related injuries to the musculoskeletal system and the brain.2 3 These potential dangers are known to clinicians who are helping youth athletes and their parents make sound decisions about injury management and sports participation. In the face of these challenges, how does the clinician fulfil his or her duty of care to youth athletes? The aim of this editorial is to illustrate how different ethical standards can help guide better shared decisions in sports medicine clinical practice. Youth athletes are a particularly vulnerable group because their life plans are still developing. Adding to this complexity is an increasing trend towards professionalisation in youth sport. When arriving at a decision in a clinical dilemma, one or several ethical standards may help the decision-making team evaluate if a decision is ethically justifiable. The 2018 International Olympic Committee consensus on paediatric ACL injury4 outlined six ethical standards (box 1) that may apply to different situations in sports medicine clinical practice.Box 1 ### Six ethical standards that can apply to sports medicine clinical scenarios 1. Best interests 5: what is in the youth athlete’s best long-term interests. 2. Harm principle 6: a threshold below which the clinician should not acquiesce to a parent-led …

Background: Knee reinjury after anterior cruciate ligament (ACL) reconstruction is common and increases the risk of osteoarthritis. There is sparse evidence to guide return to sport (RTS) decisions in this population. Objectives: To assess the relationship between knee reinjury after ACL reconstruction and 1) return to level I sports, 2) timing of return to sports, and 3) knee function prior to return. Methods: 106 patients who participated in pivoting sports participated in this prospective two year cohort study. Sports participation and knee reinjury were recorded monthly. Knee function was assessed with the Knee Outcome Survey–Activities of Daily Living Scale, global rating scale of function, and quadriceps strength and hop test symmetry. Pass RTS criteria was defined as scores >90 on all tests, failure as failing any. Results: Patients who returned to level I sports had 4.32 (p=0.048) higher reinjury rate than those who did not. The reinjury rate was significantly reduced by 51 % for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed. 38.2 % of those who failed RTS criteria suffered reinjuries versus 5.6 % of those who passed (HR: 0.16, p=0.075). More symmetrical quadriceps strength prior to return significantly reduced the knee reinjury rate. Conclusion: Returning to level I sports after ACL reconstruction leads to a more than 4-fold increase in reinjury rates over 2 years. Return to sport 9 months or later after surgery and more symmetrical quadriceps strength prior to return substantially reduces the reinjury rate.

Background: Rehabilitation before anterior cruciate ligament (ACL) reconstruction (ACLR) is effective at improving postoperative outcomes at least in the short term. Less is known about the effects of preoperative rehabilitation on functional outcomes and return-to-sport (RTS) rates 2 years after reconstruction. Purpose/Hypothesis: The purpose of this study was to compare functional outcomes 2 years after ACLR in a cohort that underwent additional preoperative rehabilitation, including progressive strengthening and neuromuscular training after impairments were resolved, compared with a nonexperimental cohort. We hypothesized that the cohort treated with extended preoperative rehabilitation would have superior functional outcomes 2 years after ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: This study compared outcomes after an ACL rupture in an international cohort (Delaware-Oslo ACL Cohort [DOC]) treated with extended preoperative rehabilitation, including neuromuscular training, to data from the Multicenter Orthopaedic Outcomes Network (MOON) cohort, which did not undergo extended preoperative rehabilitation. Inclusion and exclusion criteria from the DOC were applied to the MOON database to extract a homogeneous sample for comparison. Patients achieved knee impairment resolution before ACLR, and postoperative rehabilitation followed each cohort’s respective criterion-based protocol. Patients completed the International Knee Documentation Committee (IKDC) subjective knee form and Knee injury and Osteoarthritis Outcome Score (KOOS) at enrollment and again 2 years after ACLR. RTS rates were calculated for each cohort at 2 years. Results: After adjusting for baseline IKDC and KOOS scores, the DOC patients showed significant and clinically meaningful differences in IKDC and KOOS scores 2 years after ACLR. There was a significantly higher ( P < .001) percentage of DOC patients returning to preinjury sports (72%) compared with those in the MOON cohort (63%). Conclusion: The cohort treated with additional preoperative rehabilitation consisting of progressive strengthening and neuromuscular training, followed by a criterion-based postoperative rehabilitation program, had greater functional outcomes and RTS rates 2 years after ACLR. Preoperative rehabilitation should be considered as an addition to the standard of care to maximize functional outcomes after ACLR.

Background: Reduced quadriceps strength influences knee function and increases the risk of knee osteoarthritis. Thus, it is of significant clinical relevance to precisely quantify strength deficits in patients with knee injuries. Purpose: To evaluate isokinetic concentric quadriceps muscle strength torque values, assessed both from peak torque and at specific knee flexion joint angles, in patients with anterior cruciate ligament (ACL) injury, focal cartilage lesions, and degenerative meniscus tears. Study Design: Cohort study; Level of evidence, 3. Methods: Data were synthesized from patients included in 3 previously conducted research projects: 2 prospective cohort studies and 1 randomized controlled trial. At the time of inclusion, all patients were candidates for surgery. Isokinetic concentric quadriceps muscle strength measurements (60 deg/s) were performed at baseline (preoperative status) and after a period of progressive supervised exercise therapy (length of rehabilitation period: 5 weeks for ACL injury, 12 weeks for cartilage lesions and degenerative meniscus). Outcome measures were peak torque and torque at specific knee flexion joint angles from 20° to 70°. All patients had unilateral injuries, and side-to-side deficits were calculated. For comparisons between and within groups, we utilized 1-way analysis of variance and paired t tests, respectively. Results: In total, 250 patients were included. At baseline, cartilage patients had the most severe deficit (39.7% ± 24.3%; P < .001). Corresponding numbers for ACL and degenerative meniscus subjects were 21.7% (±13.2%) and 20.7% (±16.3%), respectively. At retest, there was significant improvement in all groups ( P < .001), with remaining deficits of 24.7% (±18.5%) for cartilage, 16.8% (±13.9%) for ACL, and 3.3% (±17.8%) for degenerative meniscus. Peak torque was consistently measured at 60° of knee flexion, whereas the largest mean deficits were measured at 30° at baseline and 70° at retest for the ACL group, at 70° at baseline and retest for the degenerative meniscus group, and at 60° at baseline and at 50° at retest for the cartilage group. Conclusion: This study underlines the importance of including torque at specific knee flexion joint angles from isokinetic assessments to identify the most severe quadriceps muscle strength deficits. Furthermore, it confirms the importance of progressive exercise therapy interventions before potential surgery in patients with knee injuries.

Background:Patients usually return to pivoting sports between 6 months and 1 year after anterior cruciate ligament (ACL) reconstruction, but no matched study has so far examined 1-year return to sport rates in nonoperatively and operatively treated ACL-injured patients.Hypothesis:Anterior cruciate ligament-injured patients following a nonoperative treatment course, including recommendation of activity modification, will have lower return to pivoting sport rates than operatively treated patients 1 year after baseline testing/surgery, when matched by preinjury sports activity, age, and sex.Study Design:Cohort study; level of evidence, 3.Methods:Sixty-nine nonoperatively treated ACL-injured patients were pair-matched with 69 operatively treated patients (n = 138), based on specific preinjury sport, age, and sex. Nonoperatively treated patients were recommended not to return to level I sports. Patients were defined as nonoperatively or operatively treated according to their status at follow-up. The baseline and follow-up testing included registration of sports participation, KT-1000 arthrometer measurements, 4 hop tests, and patient-reported outcome measures. McNemars test and paired t tests or Wilcoxon test were used to compare outcomes of nonoperatively and operatively treated patients.Results:No significant baseline differences were found. At 12.9 ± 1.2 months (mean ± standard deviation) after baseline testing (nonoperative) and 12.7 ± 1.2 months after surgery (operative), there was no significant difference in overall return to sport rates (nonoperative: 68.1%, operative: 68.1%, P = 1.00), or in return to level I sport rates (nonoperative: 54.8%, operative: 61.9%, P = .66). Nonoperatively treated patients who participated in level I sports before injury had a significantly lower return to sport rate (54.8%) than nonoperatively treated patients who participated in level II sports (88.9%, P = .003). The nonoperatively treated patients had significantly higher knee joint laxity, but significantly better hop test limb symmetry indexes, Knee Outcome Survey Activities of Daily Living scores, and International Knee Documentation Committee Subjective Knee Form 2000 scores. None of the functional differences was larger than the smallest detectable difference.Conclusion:Anterior cruciate ligament-injured patients following a nonoperative treatment course, including recommendations of activity modifications, and operatively treated patients did not have significantly different rates of returning to pivoting sports after 1 year in this pair-matched cohort study. Clinicians should be aware of a potentially high level of noncompliance to recommendations of activity modifications. Although these results show that it is possible for nonoperatively treated patients to return to sport after rehabilitation, future follow-ups are needed to examine whether these patients maintain sports participation over time, and what long-term consequences they may suffer regarding subsequent injuries and knee osteoarthritis.

Background: Single-legged hop tests are commonly used functional performance measures that can capture limb asymmetries in patients after anterior cruciate ligament (ACL) reconstruction. Hop tests hold potential as predictive factors of self-reported knee function in individuals after ACL reconstruction. Hypothesis: Single-legged hop tests conducted preoperatively would not and 6 months after ACL reconstruction would predict self-reported knee function (International Knee Documentation Committee [IKDC] 2000) 1 year after ACL reconstruction. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: One hundred twenty patients who were treated with ACL reconstruction performed 4 single-legged hop tests preoperatively and 6 months after ACL reconstruction. Self-reported knee function within normal ranges was defined as IKDC 2000 scores greater than or equal to the age- and sex-specific normative 15th percentile score 1 year after surgery. Logistic regression analyses were performed to identify predictors of self-reported knee function within normal ranges. The area under the curve (AUC) from receiver operating characteristic curves was used as a measure of discriminative accuracy. Results: Eighty-five patients completed single-legged hop tests 6 months after surgery and the 1-year follow-up with 68 patients classified as having self-reported knee function within normal ranges 1 year after reconstruction. The crossover hop and 6-m timed hop limb symmetry index (LSI) 6 months after ACL reconstruction were the strongest individual predictors of self-reported knee function (odds ratio, 1.09 and 1.10) and the only 2 tests in which the confidence intervals of the discriminatory accuracy (AUC) were above 0.5 (AUC = 0.68). Patients with knee function below normal ranges were over 5 times more likely of having a 6-m timed hop LSI lower than the 88% cutoff than those with knee function within normal ranges. Patients with knee function within normal ranges were 4 times more likely to have a crossover hop LSI greater than the 95% cutoff than those with knee function below normal ranges. No preoperative single-legged hop test predicted self-reported knee function within normal ranges 1 year after ACL reconstruction (all P > .353). Conclusion: Single-legged hop tests conducted 6 months after ACL reconstruction can predict the likelihood of successful and unsuccessful outcome 1 year after ACL reconstruction. Patients demonstrating less than the 88% cutoff score on the 6-m timed hop test at 6 months may benefit from targeted training to improve limb symmetry in an attempt to normalize function. Patients with minimal side-to-side differences on the crossover hop test at 6 months possibly will have good knee function at 1 year if they continue with their current training regimen. Preoperative single-legged hop tests are not able to predict postoperative outcomes.

Background: Previous studies have found significant predictors for functional outcome after anterior cruciate ligament (ACL) reconstruction; however, studies examining predictors for functional outcome in nonoperatively treated individuals are lacking. Hypothesis: Single-legged hop tests predict self-reported knee function (International Knee Documentation Committee [IKDC] 2000) in nonoperatively treated ACL-injured individuals 1 year after baseline testing. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Ninety-one nonoperatively treated patients with an ACL injury were tested using 4 single-legged hop tests on average 74 ± 30 days after injury in a prospective cohort study. Eighty-one patients (89%) completed the IKDC 2000 1 year later. Patients with an IKDC 2000 score equal to or higher than the age- and gender-specific 15th percentile score from previously published data on an uninjured population were classified as having self-reported function within normal ranges. Logistic regression analyses were performed to identify predictors of self-reported knee function. The area under the curve (AUC) from receiver operating characteristic curves was used as a measure of discriminative accuracy. Optimal limb symmetry index (LSI) cutoff for the best single-legged hop test was defined as the LSI with the highest product of sensitivity and specificity. Results: Single hop for distance symmetry indexes predicted self-reported knee function at the 1-year follow-up ( P = .036). Combinations of any 2 hop tests (AUC = 0.64-0.71) did not give a higher discriminative accuracy than the single hop alone (AUC = 0.71). A cutoff of 88% (LSI) for the single hop revealed a sensitivity of 71.4% and a specificity of 71.7%. Conclusion: The single hop for distance (LSI) significantly predicted self-reported knee function after 1 year in nonoperatively treated ACL-injured patients. Combinations of 2 single-legged hop tests did not lead to higher discriminative accuracy than the single hop alone.

Background: More than 50% of highly active patients with an anterior cruciate ligament (ACL) injury who choose nonsurgical treatment (active rehabilitation alone) have successful 2-year outcomes and comparable knee function to an uninjured population. Early predictive factors for a successful outcome may aid treatment decision making in this population. Purpose: To identify early predictors of a successful 2-year outcome in those who choose nonsurgical treatment of an ACL injury. Study Design: Cohort study; Level of evidence, 2. Methods: This prospective cohort study consisted of ACL-injured athletes who were consecutively screened for inclusion. A total of 300 patients were included from 2 sites (Oslo, Norway, and Delaware, USA), and the 118 patients who initially chose not to undergo ACL reconstruction were included. All patients participated in pivoting sports before the injury, and none had significant concomitant injuries. A successful 2-year outcome was defined as having 2-year International Knee Documentation Committee (IKDC) scores ≥15th normative percentile and not undergoing ACL reconstruction. Multivariable logistic regression models were built using demographic and knee function data (quadriceps muscle strength, 4 single-leg hop tests, IKDC score, and Knee Outcome Survey–Activities of Daily Living Scale [KOS-ADLS] score) collected at baseline or after a 5-week neuromuscular and strength training (NMST) rehabilitation program. Results: After 2 years, 52 of 97 (53.6%) patients had a successful outcome. In the multivariable baseline model, older age, female sex, better performance on the single-leg hop test, and a higher KOS-ADLS score were significantly associated with successful 2-year outcomes. After the 5-week NMST rehabilitation program, older age, female sex, and a higher IKDC score increased the odds of a successful 2-year outcome. The 2 models had comparable predictive accuracy (post-NMST area under the curve [AUC], 0.78 [95% CI, 0.68-0.88]; baseline AUC, 0.81 [95% CI, 0.72-0.89]). Conclusion: Clinicians and patients can be more confident in a nonsurgical treatment choice (active rehabilitation alone) in athletes who are female, are older in age, and have good knee function, as measured by single-leg hop tests and patient-reported outcome measures, early after an ACL injury. Prediction models that include measures of knee function, assessed either before or after rehabilitation, can estimate 2-year prognoses for nonsurgical treatment and thereby assist shared treatment decision making.

Purpose: To review the current knowledge on anterior cruciate ligament (ACL) injury prevention and ACL rehabilitation in individuals who have not yet reached musculoskeletal maturity. Methods: This is a narrative review based on a targeted and systematic literature search for paediatric ACL injury risk factors, injury prevention and rehabilitation. Results: The search strategies resulted in 119 hits on risk factor studies, 57 hits on prevention and 37 hits on rehabilitation. Modifiable risk factors for ACL injury are largely unknown in the paediatric population. ACL injury prevention using neuromuscular training is highly successful in the adolescent population, and existing injury prevention programmes are cost-effective. The efficacy of ACL injury prevention programmes in children is, however, investigated to a markedly lesser degree. Paediatric ACL injury rehabilitation is poorly described, although supervised active rehabilitation progressed through phases with functional milestones is generally encouraged. Conclusion: Although limited, current evidence supports implementation of injury prevention programmes in female football players from the age of 12. Supervised active rehabilitation where progression is guided by functional milestones is also advocated. Future identification of modifiable risk factors is needed to design prevention programmes for younger children. There is a need for international multicentre studies on treatment algorithms and rehabilitation to increase knowledge on the short- and long-term outcomes following existing algorithms.

Because ACL reconstruction does not automatically lead to successful outcomes and return to play,1 ,2 active rehabilitation is a realistic option that is being adopted by an increasing number of patients.3 In the Delaware-Oslo ACL Cohort Study, we found no differences in 2-year knee function, sports participation or new knee injuries between patients treated with ACL reconstruction followed by progressive preoperative and postoperative active rehabilitation, and patients treated with active rehabilitation alone.4 In our 2015 paper, we found that 86–94% of our ACL reconstruction and active rehabilitation group reported 2-year Knee injury and Osteoarthritis Outcome Score (KOOS) within …

BackgroundSecondary meniscal tears after ACL injuries increase the risk of knee osteoarthritis. The current literature on secondary meniscal injuries after ACL injury is not consistent and may have methodological shortcomings. This protocol describes the methods of a systematic review investigating the rate of secondary meniscal injuries in children and adults after treatment (operative or non-operative) for ACL injury.MethodsWe will search electronic databases (Embase, Ovid Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, PEDro and Google Scholar) from database inception. Extracted data will include demographic data, methodology, intervention details and patient outcomes. Risk of bias will be assessed using the Newcastle Ottawa checklist for cohort studies. Article screening, eligibility assessment, risk of bias assessment and data extraction will be performed in duplicate by independent reviewers. A proportion meta-analysis will be performed if studies are homogeneous (I2Ethics and disseminationThis protocol is written according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses, and was registered in the International Prospective Register of Systematic Reviews on 22 March 2016.Trial registration numberCRD42016036788.

Cohort study, cross-sectional.To determine if self-reported knee function assessed with the International Knee Documentation Committee 2000 Subjective Knee Form (IKDC 2000) could discriminate between successful and nonsuccessful performance on return-to-activity criteria (RTAC) tests after anterior cruciate ligament (ACL) reconstruction.Selecting appropriate performance-based and patient-reported tests that can detect side-to-side asymmetries, assess global knee function, and determine a participant's readiness to return to activity after ACL reconstruction can be a challenge for rehabilitation specialists. A simple tool or questionnaire to identify athletes with neuromuscular impairments or activity limitations could provide rehabilitation specialists with crucial data pertinent to their patients' current knee function and readiness to return to higher-level activities.One hundred ninety-four level I and level II athletes who underwent ACL reconstruction participated in the study. One hundred fifty-eight athletes at 6 months after ACL reconstruction and 141 of the athletes at 12 months after ACL reconstruction completed a battery of functional tests to determine readiness to return to activity and the IKDC 2000 to determine self-reported knee function. For each athlete, status on the RTAC test battery was dichotomized into "passed" or "failed," and status on the IKDC 2000 scores was dichotomized into "within" or "below" age- and sex-matched normal ranges. Comparisons were made between status on the RTAC test battery and the IKDC 2000 using chi-square tests. Accuracy statistics were also calculated.Six months after ACL reconstruction, 112 athletes (70.9%) failed RTAC and 76 (48.1%) were classified as having self-reported knee function below normal ranges. Among the 76 participants with IKDC 2000 scores below normal ranges, 69 (90.8%) failed the RTAC test battery (P.001). However, among the 82 participants whose IKDC 2000 scores were within normal limits at 6 months, only 39 (47.6%) passed the RTAC test battery (P = .74). Twelve months after ACL reconstruction, 67 athletes (47.5%) failed RTAC and 31 (22.0%) had knee function below normal ranges. Among the 31 participants with IKDC 2000 scores below normal ranges, 25 (80.6%) failed the RTAC test battery (P.001). However, among the 110 participants whose IKDC 2000 scores were within normal limits at 12 months, only 68 (61.8%) passed the RTAC test battery (P = .017).The IKDC 2000 may be a clinically relevant tool to determine the timeliness or necessity of RTAC testing. For scores obtained 6 and 12 months after ACL reconstruction, low IKDC 2000 scores were reasonably indicative of failure on the RTAC test battery, whereas normal IKDC 2000 scores were not predictive of passing scores on the RTAC test battery.

Background: While there are many opinions about the expected knee function, sports participation, and risk of knee reinjury following nonsurgical treatment of injuries of the anterior cruciate ligament (ACL), there is a lack of knowledge about the clinical course following nonsurgical treatment compared with that after surgical treatment. Methods: This prospective cohort study included 143 patients with an ACL injury. Isokinetic knee extension and flexion strength and patient-reported knee function as recorded on the International Knee Documentation Committee (IKDC) 2000 form were collected at baseline, six weeks, and two years. Sports participation was reported monthly for two years with use of an online activity survey. Knee reinjuries were reported at the follow-up evaluations and in a monthly online survey. Repeated analysis of variance (ANOVA), generalized estimating equation (GEE) models, and Cox regression analysis were used to analyze group differences in functional outcomes, sports participation, and knee reinjuries, respectively. Results: The surgically treated patients (n = 100) were significantly younger, more likely to participate in level-I sports, and less likely to participate in level-II sports prior to injury than the nonsurgically treated patients (n = 43). There were no significant group-by-time effects on functional outcome. The crude analysis showed that surgically treated patients were more likely to sustain a knee reinjury and to participate in level-I sports in the second year of the follow-up period. After propensity score adjustment, these differences were nonsignificant; however, the nonsurgically treated patients were significantly more likely to participate in level-II sports during the first year of the follow-up period and in level-III sports over the two years. After two years, 30% of all patients had an extensor strength deficit, 31% had a flexor strength deficit, 20% had patient-reported knee function below the normal range, and 20% had experienced knee reinjury. Conclusions: There were few differences between the clinical courses following nonsurgical and surgical treatment of ACL injury in this prospective cohort study. Regardless of treatment course, a considerable number of patients did not fully recover following the ACL injury, and future work should focus on improving the outcomes for these patients. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

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.

Background The current methods measuring sports activity after anterior cruciate ligament (ACL) injury are commonly restricted to the most knee-demanding sports, and do not consider participation in multiple sports. We therefore developed an online activity survey to prospectively record the monthly participation in all major sports relevant to our patient-group. Objective To assess the reliability, content validity and concurrent validity of the survey and to evaluate if it provided more complete data on sports participation than a routine activity questionnaire. Methods 145 consecutively included ACL-injured patients were eligible for the reliability study. The retest of the online activity survey was performed 2 days after the test response had been recorded. A subsample of 88 ACL-reconstructed patients was included in the validity study. The ACL-reconstructed patients completed the online activity survey from the first to the 12th postoperative month, and a routine activity questionnaire 6 and 12 months postoperatively. Results The online activity survey was highly reliable (κ ranging from 0.81 to 1). It contained all the common sports reported on the routine activity questionnaire. There was a substantial agreement between the two methods on return to preinjury main sport (κ=0.71 and 0.74 at 6 and 12 months postoperatively). The online activity survey revealed that a significantly higher number of patients reported to participate in running, cycling and strength training, and patients reported to participate in a greater number of sports. Conclusions The online activity survey is a highly reliable way of recording detailed changes in sports participation after ACL injury. The findings of this study support the content and concurrent validity of the survey, and suggest that the online activity survey can provide more complete data on sports participation than a routine activity questionnaire.

Background Knowledge of skill-related risk factors for injury in football is limited. Objective To investigate whether there is an association between football skills and risk of injury in football. Study Design Prospective cohort study of the incidence of injuries and a retrospective evaluation of the players9 skill-level. Methods Exposure and injuries were registered prospectively in 82 of 125 football teams (1665 of 2540 female Norwegian amateur players aged 13–17 years) throughout one football season (March–October 2007). A standardised questionnaire designed to assess the football skills of each player was completed by the coaches after the season. Results Across the different skill attributes, the injury incidence in the high-skilled players varied from 4.4 to 4.9 injuries per 1000 player hours, compared to 2.8 to 4.0 injuries per 1000 player hours in the low-skilled players. Players skilled at ball receiving, passing and shooting, heading, tackling, decision-making when in ball possession or in defence and physically strong players were at significantly greater risk of sustaining any injury, an acute injury and a contact injury than their less skilled teammates (rate ratio: 1.50–3.19, all p Conclusions Players with high levels of football skill were at greater risk of sustaining injuries than their less skilled teammates.