In an attempt to quantify the current standards in surgical procedures and rehabilitation protocols utilized to treat patients with anterior cruciate ligament (ACL)-deficient knees, a 19-question survey was sent to members of the Hawaii Orthopedic Association. The findings indicated that only 54% (30/56) of the respondents were performing ACL reconstructions, of which 87% (26/30) were performing an intra-articular procedure and none were performing extra-articular procedures exclusively. The findings further indicate that 80% (24/30) of the 30 respondents performing ACL reconstructions were using an arthroscopically assisted, bone-tendon-bone autograft procedure. However, in marked contrast to the uniformity that existed concerning the surgical procedure, there was a drastic difference in the rehabilitation protocols and procedures that were recommended postoperatively. The most apparent differences in rehabilitation protocols existed in the utilization and initiation of open versus closed type kinetic chain exercises and activities.
Michael R. McCarthy, Barton P. Buxton, W. Douglas B. Hiller, James R. Doyle and Denis Yamada
Michael J. Axe, Katherine Linsay and Lynn Snyder-Mackler
The purpose of this study was to determine whether there was a relationship between knee hyperextension and intra-articular pathology in 100 consecutive patients whose sole ligament injury was an arthroscopically confirmed anterior cruciate ligament (ACL) rupture. Hyperextension of both knees was measured using a supine heel-height measurement of high reliability. There was more articular damage to the total joint, lateral joint, and lateral meniscus in patients who hyperextended than in those who did not. There was more articular damage to the total joint and medial joint in patients who were chronically ACL deficient than in those who were acutely or subacutely ACL deficient. The results demonstrate that individuals with ACL injuries whose knees hyperextend 3 cm or more sustain significantly more joint damage at the time of injury than in those whose knees hyperextend less than 3 cm. This study further defines the role of knee hyperextension in ACL injuries and offers a useful and reliable means of measuring knee hyperextension.
Michael D. Ross, Shelly Hooten and Darren Moore
To determine the relationship between asymmetries in lower leg girth and standing heel-rise after anterior cruciate ligament (ACL) reconstruction.
15 at a mean of 30 d after ACL reconstruction.
Lower leg girth and number of repetitions performed on the standing heel-rise test.
A significant decrease in lower leg girth and number of repetitions performed on the standing heel-rise test for the involved leg. There was also a low correlation between asymmetries in lower leg girth and standing heel-rise test (r = .25).
Ankle plantar-flexor endurance should be considered when developing rehabilitation programs for the early stages after ACL reconstruction. In this study the ankle of the involved leg attained a significantly smaller angle of maximal standing plantar flexion, suggesting that ankle range of motion should also be assessed. Caution should be used in predicting standing heel-rise asymmetries from asymmetries in lower leg girth in ACL-reconstructed patients.
Paul A. Borsa, Scott M. Lephart and James J. Irrgang
We compared the outcome measures of three knee scoring systems currently used to measure disability in anterior cruciate ligament (ACL)–deficient athletes. Twenty-nine ACL-deficient athletes completed three scoring systems (the Lysholm Knee Scoring System, a modified version of the Cincinnati Knee Scoring System, and the Knee Outcome Survey). Results demonstrate statistically significant mean differences and linear relationships between the outcome measures for the three scoring systems. The Knee Outcome Survey appears to provide valid measures of disability and indicates that our subjects functioned well with activities of daily living but became symptomatic and functionally limited with sports. The outcome measures also indicate that the Lysholm system is more specific to activities of daily living, while the modified Cincinnati is more specific to sports. We recommend that standard scoring systems be developed to provide measures of functional disability in athletes who experience knee injuries.
Carrie B. Scherzer, Britton W. Brewer, Allen E. Cornelius, Judy L. Van Raalte, Albert J. Petitpas, Joseph H. Sklar, Mark H. Pohlman, Robert J. Krushell and Terry D. Ditmar
To examine the relationship between self-reported use of psychological skills and rehabilitation adherence.
Prospective correlational design.
Outpatient physical-therapy clinic specializing in sports medicine.
Fifty-four patients (17 women and 37 men) undergoing rehabilitation after anterior-cruciate-ligament reconstruction.
Main Outcome Measures:
An abbreviated version of the Sports Injury Survey (Ievleva & Orlick, 1991) was administered approximately 5 weeks after surgery to assess use of goal setting, imagery, and positive self-talk. Four adherence measures were obtained during the remainder of rehabilitation: attendance at rehabilitation sessions, practitioner ratings of patient adherence at rehabilitation sessions, patient self-reports of home exercise completion, and patient self-reports of home cryotherapy completion.
Goal setting was positively associated with home exercise completion and practitioner adherence ratings. Positive self-talk was positively correlated with home exercise completion.
Use of certain psychological skills might contribute to better adherence to sport-injury rehabilitation protocols.
John A. Nyland, Dean P. Currier, J. Michael Ray and Mitchell J. Duby
This paper discusses function changes during an accelerated rehabilitation program at 6, 10, and 52 weeks postsurgery for a college athlete following anterior cruciate ligament reconstruction/meniscectomy of the left knee. The effects of combined pulsed electromagnetic field (PEMF) and neuromuscular electrical stimulation (NMES) on knee extensor torque, thigh girth, and pain level are presented. PEMF-NMES decreased stimulation pain by 76%. Knee extensor isometric torque increased by 23%, and thigh girth decreased less than 5% at 6 weeks. Knee extensor isokinetic torque was 13% and 3% deficient at 90°/s and 240°/s, and standing single-leg broad jump distance was 19% deficient at 10 weeks. Knee extensor isokinetic torque was 1% and 1.5% greater at 90°/s and 240°/s, and standing single-leg broad jump distance was 11% deficient at 52 weeks. Knee anterior laxity was 2 mm at 10 weeks and 3 mm at 52 weeks. PEMF-NMES appears to comfortably enhance knee extensor torque gains and diminish thigh girth loss. Despite early return to practice, functional deficit remained and anterior laxity was increased at 52 weeks.
Hidenori Tanikawa, Hideo Matsumoto, Ikki Komiyama, Yoshimori Kiriyama, Yoshiaki Toyama and Takeo Nagura
It has been suggested that noncontact anterior cruciate ligament injury commonly occurs during sports requiring acute deceleration or landing motion and that female athletes are more likely to sustain the injury than male athletes. The purpose of this study was to make task-to-task and male-female comparisons of knee kinematics and kinetics in several athletic activities. Three-dimensional knee kinematics and kinetics were investigated in 20 recreational athletes (10 males, 10 females) while performing hopping, cutting, turning, and sidestep and running (sharp deceleration associated with a change of direction). Knee kinematics and kinetics were compared among the four athletic tasks and between sexes. Subjects exhibited significantly lower peak flexion angle and higher peak extension moment in hopping compared with other activities (P < .05). In the frontal plane, peak abduction angle and peak adduction moment in cutting, turning, and sidestep and running were significantly greater compared with hopping (P < .05). No differences in knee kinematics and kinetics were apparent between male and female subjects. Recreational athletes exhibited different knee kinematics and kinetics in the four athletic motions, particularly in the sagittal and frontal planes. Male and female subjects demonstrated similar knee motions during the four athletic activities.
Brian G. Pietrosimone, Adam S. Lepley, Hayley M. Ericksen, Phillip A. Gribble and Jason Levine
Disability is common in a proportion of patients after anterior cruciate ligament reconstruction (ACL-R). Neuromuscular quadriceps deficits are a hallmark impairment after ACL-R, yet the link between muscle function and disability is not understood.
To evaluate the ability of quadriceps strength and cortical excitability to predict self-reported disability in patients with ACL-R.
Fifteen participants with a history of ACL-R (11 female, 4 male; 172 ± 9.8 cm, 70.4 ± 17.5 kg, 54.4 ± 40.9 mo postsurgery) were included in this study. Corticospinal excitability was assessed using active motor thresholds (AMT), while strength was assessed with maximal voluntary isometric contractions (MVIC). Both voluntary strength and corticospinal excitability were used to predict disability measured with the International Knee Documentation Committee Index (IKDC).
The overall multiple-regression model significantly predicted 66% of the variance in self-reported disability as measured by the IKDC index (R 2 = .66, P = .01). Initial imputation of MVIC into the model accounted for 61% (R 2 = .61, P = .01) of the variance in IKDC. The subsequent addition of AMT into the model accounted for an insignificant increase of 5% (Δ R 2 = .05, P = .19) in the prediction capability of the model.
Quadriceps voluntary strength and cortical excitability predicted two-thirds of the variance in disability of patients with ACL-R, with strength accounting for virtually all of the predictive capability of the model.
Hayri Baran Yosmaoglu, Gül Baltaci, Defne Kaya and Hamza Ozer
The development pattern of motor coordination, strength, and functional ability during recovery from anterior cruciate ligament (ACL) reconstruction.
To investigate the relationship between motor coordination, functional ability, and strength after ACL reconstruction.
Prospective clinical follow-up study.
Sports-injury research laboratory.
20 subjects who underwent ACL reconstruction.
Real-time eccentric and concentric motor coordination were tested by a multijoint lower limb tracking-trajectory test, quadriceps and hamstring isokinetic strength were assessed by isokinetic dynamometer, and functional performance was tested with a single-leg-hop test 6 and 12 mo after ACL reconstruction.
Main Outcome Measures:
Percentage deficits of the involved lower extremity for target-tracking ability, peak torque, total work parameters of isokinetic strength, and single-leg-hop distance.
Deficits in hamstring–quadriceps isokinetic muscle strength and single-leg-hop distance significantly decreased from the 6th to the 12th mo after surgery (P < .05). There were no significant differences in muscle concentric and eccentric motor-coordination deficits of the involved side (P > .05).
Although muscle strength and functional performance clearly increased from the 6th to the 12th mo after surgery, coordination characteristics of involved side remained low. This pattern demonstrated that motor-coordination progression was not affected by strength development. Patients continued to have significant motor-coordination deficits even 12 mo postsurgery. Therefore, the authors recommend that neuromuscular-coordination exercises be included in long-term rehabilitation programs to improve motor coordination.
Tania Pizzari, Nicholas F. Taylor, Helen McBurney and Julian A. Feller
To investigate the relationship between adherence to rehabilitation and outcome after reconstructive surgery of the anterior cruciate ligament (ACL).
A prospective cohort study with adherence to rehabilitation evaluated over 8 weeks correlated with outcomes at 9 and 12 months postsurgery.
68 patients who had undergone ACL-reconstructive surgery.
Main Outcome Measures:
Adherence was measured to and during appointments and by a self-report diary of home exercise. Outcomes were measured by 6 knee-function scales and 2 hop tests.
There was a significant relationship between home-exercise adherence and many outcomes for participants under 30 years of age (r s = .33-.44). For participants age 30 and over there was a negative relationship between home-exercise adherence and outcome. There were no significant relationships between adherence to and during physical therapy appointments and outcome after ACL-reconstructive surgery.
Participants under 30 years of age who adhered to their home-exercise regimen had better functional outcome, whereas adherent participants age 30 and over experienced worse outcome with better home-exercise adherence.