useful information to direct patient intervention (Myer et al., 2010; Paterno, Myer, Ford, & Hewett, 2004). Recent evidence by Wellsandt and colleagues (2017) indicates that postoperative performance on single-legged hop tests and strength testing may be lower on the uninvolved limb compared to preoperative levels. Therefore, symmetry indexes comparing functional performance post- operatively may underestimate an individual’s performance relative to his or her preinjury status (Wellsandt et al., 2017) Participation restrictions Following ACL injury, many patients demonstrate decreased ac- tivity levels (Daniel et al., 1994; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Grindem et al., 2012; Bell et al., 2017; Spindler et al., 2018). For patients undergoing ACL reconstruction, activity limitations often continue following surgery (Hartigan et al., 2010; Loger- stedt et al., 2012). Furthermore, research indicates that individu - als approximately 28 months after ACL reconstruction (range 6-67 months) spend less time in moderate-to-vigorous physical activity and take fewer daily steps compared to age-, sex-, and sport- ing activity-matched controls (Bell et al., 2017). Factors affecting activity level after initial ACL injury include knee pain, reduced knee ROM, decreased quadriceps strength, increased knee joint effusion, knee joint instability, patient-perceived decreased knee function, and fear of reinjury. Many patients decrease participa- tion and intensity of activity levels to avoid episodes of giving way and further impairments, including pain and effusion (Eastlack et al., 1999; McCullough et al., 2012). However, some individuals demonstrate the ability to maintain their preinjury activity levels without instability (Daniel et al., 1994; Eastlack et al., 1999; Hurd, Axe, & Snyder-Mackler, 2008a; Snyder-Mackler, Fitzgerald, Bar- tolozzi, & Ciccotti, 1997). Individual assessment of each patient regarding participation restrictions is indicated to develop an in- dividualized plan of care because patients present with varying impairments following ACL injury, concomitant injuries, preinjury activity levels, goals for return to activity levels, and responses to targeted intervention (Fitzgerald, Axe, & Snyder-Mackler, 2000c; Hartigan et al., 2010; Hurd, Axe, & Snyder-Mackler, 2008a). The Knee Quality of Life 26-item (KQoL-26) questionnaire is a self- report questionnaire for patients with a suspected ligamentous or meniscal injury and is reliable, valid, and responsive (Garratt et al., 2008). The questionnaire contains 26 items with three subscales of knee-related quality of life on physical functioning, activity limi- tations, and emotional functioning. Knee-specific questionnaires The International Knee Documentation Committee Subjective Knee Form (IKDC 2000) is a knee-specific measure of symptoms, function, and sports activities used to assess patient-perceived function for a variety of knee conditions scored on a scale from 0 to 100. It is calculated from 18 items, with higher scores indicating higher self-reported levels of knee function (American Orthopae- dic Society for Sports Medicine [AOSSM], 2009). The IKDC 2000 can be used to categorize patients via their current physical activ- ity levels and assist with determining knee function by comparing current levels to preinjury levels. Level I represents sports that in- volve cutting and pivoting (e.g., soccer, basketball, and football); level II represents activities with lateral movements but less jump- ing (e.g., skiing, hockey, racquet sports, and manual labor occupa- tions); level III represents light activities (e.g., running, low-impact aerobics, and weight lifting); and level IV represents sedentary activities (e.g., housework and activities of daily living; Daniel et al., 1994; Hefti, Müller, Jakob, & Stäubli, 1993). The IKDC 2000 is reliable and is positively correlated to the physical component of the SF-36 (Irrgang et al., 2001). It is also responsive and able to detect clinically meaningful change, with a change score of 11.5 indicating improved self-perceived knee function (Irrgang, 2006). The IKDC 2000 questionnaire is more useful than the Knee Injury and Osteoarthritis Outcome Score (KOOS) for young, active indi- viduals early and within 1 year after ACL reconstruction (Hambly
tion or whether they may be due to measurement error. These are as follows (Reid et al., 2007; Ross, Langford, et al., 2002): ● 09% for the single hop 25% for the crossover hop 02% for the triple hop. ● 12.96% for the 6-m timed hop. Figure 2: Single-Legged Hop Tests
Note . Reprinted with permission. © 2013, Elizabeth Wellsandt. To avoid risk of further injury, single-legged hop tests should not be completed if pain is present during in-place unilateral hop- ping, QI is less than 70% during preoperative or nonoperative rehabilitation, QI is less than 80% during postoperative rehabilita- tion, the patient is less than 12 weeks from the time of ACL recon- struction, or the modified stroke test grade of effusion is greater than a trace. Completion of single-legged hop tests allows de- termination of limb-to-limb differences in function, allows assess- ment of patient progress throughout rehabilitation, and provides Patient-reported outcomes Patient-reported outcome measures are an important component in providing effective care following ACL injury and reconstruc- tion because self- report of current perceived function and activity levels assists in developing functional, patient-directed goals and establishing an individualized plan of care. Patient-reported out- come measures can also be used to monitor progress throughout the rehabilitative process. Although many patient-reported out- come measures exist, including general health questionnaires, knee-specific questionnaires, and activity scales, it is important to understand what each measure is evaluating in order to choose the most appropriate and relevant measures for a patient follow - ing ACL injury. General health questionnaires The Medical Outcomes Study Short Form-36 (SF-36) is a general measure of health status used for both acute and chronic condi- tions (Shapiro, Richmond, Rockett, McGrath, & Donaldson, 1996). It measures eight dimensions of health, including measures of physical function, role limitations because of physical problems, bodily pain, general health, vitality, social function, role limita- tions due to emotional problems, and mental health (Irrgang et al., 2001). Scores from the eight categories are combined to pro- duce a physical and mental component, and the SF-36 is valid and reliable across its scales in a variety of diverse patient popula- tions (McHorney, Ware, Rachel Lu, & Sherbourne, 1994). Within the ACL-injured population, the SF-36 can discriminate between acute and chronic injuries, because patients with acute ACL inju- ries score lower than those with chronic injuries, while both groups score significantly lower than norms for the general population (Shapiro et al., 1996). By assessing the general health of a patient, the SF-36 provides information on factors beyond impaired knee function that may affect patient response to rehabilitation.
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