underloading, particularly in the medial compartment, is more present 6 months after ACL reconstruction in those who develop radiographic osteoarthritis 5 years after ACL reconstruction com- pared to those who do not (Wellsandt et al., 2016). Slower walk- ing speed may also be associated with an early indicator of carti- lage degeneration within the patellofemoral compartment of the knee (Capin et al., 2020) as well as blood biomarkers indicative of osteoarthritis (Pietrosimone et al., 2016).
Altered gait biomechanics are a suspected risk factor for the development and progression of knee osteoarthritis in the ACL population (Andriacchi & Mündermann, 2006; Butler, Minick, Fer- ber, & Underwood, 2009; Webster, McClelland, Palazzolo, San- tamaria, & Feller, 2012). Recent studies have found associations between altered gait biomechanics after ACL reconstruction and early post-traumatic osteoarthritis (Capin et al., 2020; Khandha et al., 2017; Pietrosimone et al., 2017; Saxby et al., 2019; Well- sandt et al., 2016, 2020; Williams et al., 2021). Tibiofemoral joint
MEDICAL DIAGNOSIS AND IMAGING
ACL injuries (Galea, Giuffre, Dimmick, Coolican, & Parker, 2009; Kocabey, Tetik, Isbell, Atay, & Johnson, 2004). For diagnosis of ACL tears, the mean sensitivity and specificity of MRI are 78% to 80% and 100%, respectively (Van Dyck et al., 2012). However, clin- ical examination has been reported to have comparable or better diagnostic accuracy than MRI, especially with ACL injury (Kocabey et al., 2004; Madhusudhan, Kumar, Bastawrous, & Sinha, 2008). Therefore, MRI is most useful as an adjunct to physical examina- tion when clinical diagnosis is indefinite.
Diagnosis of an ACL injury can be made with reasonable certainty when a patient presents with clinical findings involving a mecha- nism of injury of deceleration/acceleration motions with dynamic valgus load, hearing or feeling a “pop” at the time of initial injury, hemarthrosis within 2 hours of initial injury, and a positive Lach- man or pivot shift test (Logerstedt, Snyder-Mackler, Ritter, Axe, & Godges, 2010a). Arthroscopy is the gold standard in diagnosis of knee pathology. Magnetic resonance imaging (MRI) is also valid in diagnosis of
OPERATIVE VERSUS NONOPERATIVE MANAGEMENT
return to multidirectional activities and to their preinjury activity levels (Beynnon, Uh et al., 2005; Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010; Hartigan et al., 2010). However, reconstructive surgery does not guarantee returning to preinjury functional level (de Jong et al., 2007; Logerstedt et al., 2013b; Lohmander et al., 2004; von Porat et al., 2004). Over the past decade, a classifica- tion system has been developed to provide therapists with a tool to assist in decision making for patient education, management, and rehabilitation interventions.
The goal of rehabilitation or surgical management of ACL deficien- cy is to restore patients’ dynamic knee stability so they can return to their desired activity level. Patients with ACL deficiency may be managed with operative or nonoperative treatment, depend- ing on their functional impairments, desired level of activity, and preferences (Eitzen, Moksnes, Snyder-Mackler, & Risberg, 2010; Magnussen et al., 2010). In the United States, ACL reconstruc- tive surgery is recommended for individuals presenting with knee instability during simple functional tasks. Surgical intervention is more likely to be recommended for young patients who intend to
CLASSIFICATION
strength or anterior knee joint laxity outcome measures between groups (Hurd, Axe, & Snyder-Mackler, 2008a). Also, a larger per- centage of patients are classified as potential noncopers than as potential copers, and these individuals are more likely to be wom- en, middle-aged adults, and patients with a noncontact mecha- nism of ACL injury (Hurd, Axe, & Snyder-Mackler, 2008b). Patients classified as potential copers may be successful in return- ing to a short period of preinjury activity levels following nonop- erative rehabilitation to finish out an athletic or work season with- out further meniscus or articular cartilage damage or episodes of the knee giving way (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000b; Fitzgerald, Axe, & Sny- der-Mackler, 2000c; Moksnes, Snyder-Mackler, & Risberg, 2008). Individuals who are able to return to preinjury sport levels with- out giving way for at least 1 year are defined as true copers; true noncopers are those unable to return to preinjury activity levels without multiple episodes of giving way (Snyder-Mackler et al., 1997). Interestingly, recent evidence from Thoma et al. suggests that even potential non-copers who undergo extended preopera- tive rehabilitation (or ‘pre-habilitation’) may be able to become true copers (Thoma et al., 2019), as discussed further below. Table 1: Potential Coper and Noncoper Classification System Classification Criteria Classification Status
Because of the poor association between passive and dynamic knee stability, not all patients who suffer an ACL injury choose to undergo reconstruction. A decision-making algorithm was published by Fitzgerald and colleagues in 2000 that allows clini- cians to determine which individuals with an ACL rupture have the highest likelihood of returning to a high level of functioning without surgical intervention in the short term (Fitzgerald, Axe, & Snyder-Mackler, 2000a). Movement coordination impairments are examined to classify patients as either potential copers or poten- tial noncopers (Fitzgerald, Axe, & Snyder-Mackler, 2000a). Poten- tial copers exhibit good dynamic knee stability and compensate well shortly after injury, whereas potential noncopers exhibit poor dynamic knee stability and have less potential for compensation (Hartigan et al., 2009). This classification system is especially useful for clinicians devel- oping rehabilitation programs for patients not undergoing ACL reconstructive surgery and those awaiting ACL surgery (Hurd, Axe, & Snyder-Mackler, 2008a). On the basis of the screening of 93 patients with acute unilateral ACL ruptures, Fitzgerald and col- leagues (2000a) developed a screening examination (Table 1) that is used to classify patients as either potential copers or potential noncopers. This screening examination consists of the single-legged 6-m timed hop, a self-reported number of episodes of the knee giving way from time of initial injury, the KOS-ADLS score, and the GRS score (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c). Patients are classified as potential cop- ers if they demonstrate a single-legged 6-m timed hop index of 80% or higher between limbs, no more than one episode of the knee giving way since initial injury, a KOS-ADLS score of 80% or higher, and a GRS score of 60% or higher (Fitzgerald, Axe, & Sny- der-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c). In- dividuals who do not meet any one of these criteria are classified as potential noncopers. Descriptive statistics from studies comparing potential copers to potential noncopers demonstrate no differences in quadriceps
• Giving way < 1 episode. • 6-meter timed hop > 80% LSI. • KOS-ADLS > 80%. • GRS > 60%.
• Potential coper : Meets all criteria. • Potential noncoper : Fails at least one of the criteria.
GRS = Global Rating Scale of Perceived Function; LSI = limb symmetry index. Note. From Western Schools, © 2018.
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