A recent Norwegian cohort study indicated that 89% of patients returned to their preinjury level of activity within 2 years of recon- struction surgery. However, 38% of the patients who did return to preinjury level of activity without meeting the return-to-activity cri- teria (reported in Table 6) incurred a subsequent injury compared to only 5.6% of those who met the criteria (Grindem et al., 2016). The Norwegian study also found that the rate of second injury was decreased by half for each month the return-to-sport activity was delayed until 9 months after reconstruction surgery (Grindem et al., 2016). These criteria might provide comprehensive assessment and capture multiple aspects of functional deficits and impairments to determine patients’ readiness because they are sensitive to the change in knee function over time (Adams et al., 2012). An- other study conducted in Qatar reported that patients who did not meet the discharge criteria (isokinetic strength testing, run- ning T test, and single-legged hop tests) before they returned to their sport activities possessed a risk four times higher for incur- ring ipsilateral graft injury compared to those who met the criteria (Kyritsis et al., 2016). Nevertheless, it is essential for clinicians to use the patients’ performance on multiple measures collectively during the decision-making process of clearing patients to return to preinjury activities.
Another study used strictness of a set of criteria to discriminate between coper and noncoper patients and to classify those who are potential candidates for successful return to preinjury activity level after ACL injury without surgery (Fitzgerald, Axe, & Snyder- Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Harti- gan et al., 2010; Hurd, Axe, & Snyder-Mackler, 2008a). R. Thomeé and colleagues (2012) reported that the success rate to which the muscle function is acceptable (indicated by achieving 90%) was 48% for the muscle strength measures and 44% for the hop measures at 24 months after surgery. However, the success rate decreased to only 22% when patients’ performance was evalu- ated on both the muscle strength and hop measures together (R. Thomeé et al., 2012). Nawasreh and colleagues (2016) reported that 50.5% of patients passed a strict battery of seven return-to- activity criteria (reported in Table 6) at 6 months after surgery, and the rate of passing the criteria increased to 57.5% and 65% at 1- and 2-year follow-ups, respectively. When patients were followed based on the return-to-activity criteria classification 6 months after surgery, those who passed the criteria at 6 months postoperatively continued to demonstrate normal knee function and limb-to-limb symmetry. Patients who failed continued to exhibit impaired knee functional performance and limb-to-limb asymmetry at 1 and 2 years after surgery. Additionally, Nawasreh and colleagues (2016) indicated that 81% and 84% of the patients who had passed the criteria at 6 months after surgery returned to participate in the preinjury activities at 1 and 2 years, respectively, after surgery, compared with only 44% and 46% of those who had failed. Di Stasi and colleagues reported that patients who pass the return- to-activity criteria demonstrated less limb-to-limb gait asymmetry compared to those who failed (Di Stasi et al., 2013). Both operative and nonoperative treatment options are viable for managing patients with ACL injury. However, it would be difficult to conclude the effectiveness of each treatment option without using measures that determine the success of patient manage- ment. Therefore, there should be consensus on a set of measures used as criteria to define successful outcomes after nonoperative and operative ACL management. Identifying such criteria may help assess the effectiveness of the physical therapy practices and help clinicians to direct the rehabilitation program to fulfill the successful outcomes. A set of measures have been agreed upon by sports medicine professionals to identify the success out- come criteria after ACL injury and reconstructive surgery (Lynch et al., 2013). These measures included return-to-sport activities, restoration of normal knee function, and limb-to-limb quadriceps Performance-based and patient-reported measures Most patients demonstrate dynamic knee instability, poor func- tional performance, and lowered perception of their knee func- tion early after ACL injury (Ageberg et al., 2008; Eitzen, Moksnes, Snyder-Mackler, Engebretsen, & Risberg, 2010; Fitzgerald, Axe, & Snyder-Mackler, 2000a; Moksnes & Risberg, 2009; Moksnes et al., 2008; Muaidi et al., 2007; Neeter et al., 2006; Tagesson et al., 2008). However, a small group of patients demonstrate dynamic knee stability and higher self-perception of knee function early af- ter ACL injury (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzger- ald, Axe, & Snyder-Mackler, 2000c; Moksnes & Risberg, 2009; Moksnes et al., 2008). Patients who are managed nonoperatively scored their knee functional level at near normal to normal levels on self-reported measures at 1 year after ACL injury, maintained their functional level at 3 years, and had a modest decline in func - tion at 15 years (Kostogiannis et al., 2007; Moksnes & Risberg, 2009). Administering neuromuscular training and progressive quadriceps strength as part of nonoperative management result- ed in positive short- and long-term effects on knee dynamic stabil- ity, knee functional performance, patient-reported knee function measures, and knee joint health (Chmielewski, Hurd, Rudolph,
As noted above, the healing timeframe is essential. Patients with ACL reconstruction should consider waiting at least 9 to 12 months after surgery to resume unrestricted sports participation in jumping, cutting, and pivoting sports (Grindem et al., 2016), although considerable conflicting evidence exists and some sug- gest waiting even longer (Nagelli & Hewett, 2017). In contrast, patients with ACL deficiency can begin participation in sport ac- tivities once they pass return-to-sport criteria. KNEE FUNCTIONAL OUTCOMES AFTER ACL INJURY AND RECONSTRUCTION SURGERY
strength symmetry, demonstration of no joint effusion, and no re- ports of episodes of giving way or reinjury (Lynch et al., 2013). Successful outcomes following nonoperative or operative man- agements of ACL injury are often measured by achieving of limb- to-limb symmetry during clinical and functional testing, having patient satisfaction of perceived knee function, restoring normal knee function, return to preinjury levels of activity, and minimizing the second knee injuries (Logerstedt, Snyder-Mackler, Ritter, Axe, & Godges, 2010b; Lynch et al., 2013). In this section, we discuss outcome measures related to patients’ functional performance, patient-reported measures, return to activity, and knee reinjury af- ter both non-operated and operated ACL management. Axe, & Snyder-Mackler, 2005; Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000b; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Hurd, Axe, & Snyder-Mackler, 2008a; Logerstedt et al., 2010a; Moksnes, Engebretsen, Eitzen, & Ris- berg, 2013). In studies that investigated single-legged hop tests as a functional outcome measure, patients had near normal or normal limb symmetry at 1 year (de Jong et al., 2007; Moksnes & Risberg, 2009) and maintained this function at 4 years after ACL injury (Moksnes & Risberg, 2009). Ageberg and colleagues report- ed good to normal quadriceps strength up to 5 years after ACL injury (Roberts, Ageberg, Andersson, & Fridén, 2007). In a 2008 study, 70% of patients initially classified as noncopers became true copers following nonoperative rehabilitation, as demonstrated by return to previous activity level without episodes of giving way 1 year after injury (Moksnes & Risberg, 2009). Multi- ple studies have reported good self-reported outcomes following nonoperative management of ACL injury, indicating that surgical reconstruction is not mandatory in all cases for good results.
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