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Fiona McVeigh and Stephen M. Pack

Background:

Research involving long-term follow-up of patients after successful anterior cruciate ligament reconstruction (ACLR) has shown that return-to-sport rates are not as good as would be expected despite many patients’ having normal knee-function scores. The psychological component, specifically fear of reinjury, plays a critical role in determining patients’ return to play and is frequently underestimated. Little is known about the recognition and intervention from the therapist’s perspective.

Aim:

To gain a greater understanding of the views of sports rehabilitators and athletic rehabilitation therapists on recognition of fear of reinjury in clients after ACLR.

Method and Design:

A qualitative approach, consisting of semistructured interviews with a purposive sample of 8 participants, sports rehabilitators, or athletic rehabilitation therapists. This population has been largely unexamined in this context in previous research.

Main Findings:

Thematic analysis yielded 2 main themes: communication and education. Participants discussed the importance of communication in the client–therapist relationship and how it is used in addressing misinformation and fear of reinjury. All participants used education in outlining the rehabilitation pathway and dealing with those providing social support around the client. Issues emerged relating to therapists’ recognition of observable signs of fear of reinjury in the clinical setting. Overall, participants thought that fear of reinjury was not a barrier to return to play after ACLR.

Conclusion:

There is a need for more education of therapists on recognizing fear of reinjury and the appropriate use of psychological intervention skills as a method for dealing with this throughout the rehabilitation process.

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Kevin R. Ford, Christopher A. DiCesare, Gregory D. Myer and Timothy E. Hewett

Context: Biofeedback training enables an athlete to alter biomechanical and physiological function by receiving biomechanical and physiological data concurrent with or immediately after a task. Objective: To compare the effects of 2 different modes of real-time biofeedback focused on reducing risk factors related to anterior cruciate ligament injury. Design: Randomized crossover study design. Setting: Biomechanics laboratory and sports medicine center. Participants: Female high school soccer players (age 14.8 ± 1.0 y, height 162.6 ± 6.8 cm, mass 55.9 ± 7.0 kg; n = 4). Intervention: A battery of kinetic- or kinematic-based real-time biofeedback during repetitive double-leg squats. Main Outcome Measures: Baseline and posttraining drop vertical jumps were collected to determine if either feedback method improved high injury risk landing mechanics. Results: Maximum knee abduction moment and angle during the landing was significantly decreased after kinetic-focused biofeedback (P = .04). The reduced knee abduction moment during the drop vertical jumps after kinematic-focused biofeedback was not different (P = .2). Maximum knee abduction angle was significantly decreased after kinetic biofeedback (P < .01) but only showed a trend toward reduction after kinematic biofeedback (P = .08). Conclusions: The innovative biofeedback employed in the current study reduced knee abduction load and posture from baseline to posttraining during a drop vertical jump.

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Lindsey K. Lepley, Abbey C. Thomas, Scott G. McLean and Riann M. Palmieri-Smith

Context:

As individuals returning to activity after anterior cruciate ligament reconstruction (ACLr) likely experience fatigue, understanding how fatigue affects knee-muscle activation patterns during sport-like maneuvers is of clinical importance. Fatigue has been suggested to impair neuromuscular control strategies. As a result, fatigue may place ACLr patients at increased risk of developing posttraumatic osteoarthritis (OA).

Objective:

To determine the effects of fatigue on knee-muscle activity post-ACLr.

Design:

Case control.

Setting:

University laboratory.

Participants:

12 individuals 7–10 mo post-ACLr (7 male, 5 female; age 22.1 ± 4.7 y; 1.8 ± 0.1 m; mass 77.7 ± 11.9 kg) and 13 controls (4 male, 9 female; age 22.9 ± 4.3 y; 1.7 ± 0.1 m; mass 66.9 ± 9.8 kg).

Interventions:

Fatigue was induced via repetitive sets of double-leg squats (n = 8), which were interspersed with sets of single-leg landings (n = 3), until squats were no longer possible.

Main Outcome Measures:

2 × 2 repeated-measures ANOVA was used to detect the main effects of group (ACLr, control) and fatigue state (prefatigue, postfatigue) on quadriceps:hamstring cocontraction index (Q:H CCI).

Results:

All subjects demonstrated higher Q:H CCI at prefatigue compared with postfatigue (F 1,23 = 66.949, P ≤ .001). Q:H CCI did not differ between groups (F 1,23 = 0.599, P = .447).

Conclusions:

The results indicate that regardless of fatigue state, ACLr individuals are capable of restoring muscle-activation patterns similar to those in healthy subjects. As a result, excessive muscle cocontraction, which has been hypothesized as a potential mechanism of posttraumatic OA, may not contribute to joint degeneration after ACLr.

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Mason D. Smith and David R. Bell

Context:

Anterior cruciate ligament (ACL) reconstruction is the standard of care for individuals with ACL rupture. Balance deficits have been observed in patients with ACL reconstruction (ACLR) using advanced posturography, which is the current gold standard. It is unclear if postural-control deficits exist when assessed by the Balance Error Scoring System (BESS), which is a clinical assessment of balance.

Objective:

The purpose of this study is to determine if postural-control deficits are present in individuals with ACLR as measured by the BESS.

Participants:

Thirty participants were included in this study. Fifteen had a history of unilateral ACLR and were compared with 15 matched controls.

Interventions:

The BESS consists of 3 stances (double-limb, single-limb, and tandem) on 2 surfaces (firm and foam). Participants begin in each stance with hands on their hips and eyes closed while trying to stand as still as possible for 20 s.

Main Outcome Measures:

Each participant performed 3 trials of each stance (18 total), and errors were assessed during each trial and summed to create a total score.

Results:

We observed a significant group × stance interaction (P = .004) and a significant main effect for stance (P < .001). Post hoc analysis revealed that the ACLR group had worse balance on the single-leg foam stance than did controls. Finally, the reconstructed group had more errors when total BESS score was examined (P = .02).

Conclusions:

Balance deficits exist in individuals with ACLR as measured by the BESS. Total BESS score was different between groups. The only condition that differed between groups was the single-leg stance on the unstable foam surface.

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Jesse C. Christensen, Laura R. Goldfine and Hugh S. West

Study Design:

Prospective randomized clinical trial.

Methods and Measures:

Thirty-six patients who had a primary anterior cruciate ligament reconstruction (ACL-R) with a semitendinosus-gracilis (STG) autograft from a single orthopedic surgeon were prospectively randomized into 2 groups. Nineteen patients were randomized to the aggressive group (53% male, mean age 30.1 + 10.5 y) and 17 to the nonaggressive group (88% male, mean age 33.1 + 10.9 y). Impairment measures of anteroposterior (A-P) knee laxity, range of motion (ROM), and peak isometric force (PIF) values were obtained 12 wk postoperatively. Subjective response to the International Knee Documentation Committee knee form (IKDC) was collected 1, 12, and 24 wk postoperatively. One-way ANOVA was used to analyze differences between groups at 12 wk for A-P knee laxity, ROM, and PIF. Differences between the groups for the IKDC scores were determined using 1-way ANOVA with repeated measures 1, 12, and 24 wk postoperatively. Bonferroni adjustment was used for multiple comparisons.

Results:

There were no differences between the groups for the baseline characteristics (P > .05). There was no difference found between the groups in respect to A-P knee laxity, ROM, or PIF at 12 wk (P > .05). Further analysis also showed no significant differences in the IKDC scores between groups at 12 or 24 wk (P > .05).

Conclusions:

No differences were found between early aggressive and nonaggressive rehabilitation after an isolated ACL-R using STG autografts for the primary outcomes of A-P knee laxity and subjective IKDC score. In addition, no differences were observed for secondary outcomes between groups for differences in ROM and PIF values.

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Anis Rostami, Amir Letafatkar, Alli Gokeler and Mehdi Khaleghi Tazji

Injury of the anterior cruciate ligament (ACL) is one of the most common ligament injuries during sports activities. 1 ACL injury is associated with long recovery times and high socioeconomic costs. 2 Approximately 70% of ACL injury mechanisms are noncontact 2 and commonly occur in sports such

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Özlem Feyzioğlu, Özgul Öztürk, Bilsen Sirmen and Selim Muğrabi

Anterior cruciate ligament (ACL), which plays a role in the dynamic and static stabilization of the knee joint, is one of the most common injured ligaments in traumatic knees. 1 ACL rupture is commonly seen in younger, active, and athletic individuals and causes short- and long-term morbidity

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Rod A. Harter, Louis R. Osternig and Kenneth M. Singer

This study evaluated knee joint position sense in the ACL-reconstructed and contralateral normal knees of 48 male and female subjects (M age 27.6 ± 6.9 yrs). Subjects were blindfolded and tested on their ability to actively reproduce five passively placed knee positions at 5° intervals between 35 and 15° of knee flexion. Mean algebraic target angle error and mean absolute error values were measured in degrees. The grand mean absolute error for the postsurgical knees at all positions was 5.4 ± 3.2°, compared with 5.2 ± 2.7° for the normal contralateral knees. There were no significant differences in knee joint position sense between the postsurgical and normal contralateral limbs at any of the five positions tested. Pivot shift, anterolateral rotatory instability, and Lachman test results were poorly correlated with knee joint position sense. The results suggest that if knee joint position sense was indeed disrupted by ACL injury and reconstructive surgery, related sensory mechanisms compensated for any proprioceptive loss prior to the minimum 2-yr postsurgical follow-up period employed in our study.

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Jatin P. Ambegaonkar, Sandra J. Shultz, David H. Perrin and Mark R. Schulz

Edited by Mary Barnum