respectively, after surgery. These results may support the notion of using a strict testing battery of objective measures to assess different aspects of patients’ readiness to return to preinjury ac- tivities. Moreover, it helps clinicians to identify patients with functional deficits who are at high risk for second ACL injury, because these deficits might become more exaggerated during participation in high-demand activities. This approach requires incorporat- ing appropriate intervention to resolve patients’ deficits before returning to high-physical demand activities. According to one study, a test battery of performance-based and patient-reported outcomes demonstrated that patients who successfully returned to high-level activity after nonoperative management of an ACL injury had an average of less than 10% deficit on their initial evalu- ation scores (see Table 7 for a list of clinical measures that can be used for the initial evaluation (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder- Mackler, 2000c).
Table 7: Performance-Based and Patient-Reported Measures Performance-Based Measures
Patient-Reported Measures
● KOS-ADLS. ● Global rating scale. ● IKDC 2000.
• Quadriceps strength (MVIC or peak torque). • Single-legged hop tests: ○ Single hop for distance. ○ Cross-over hop for distance. ○ Triple hop for distance. ○ 6-m timed hop.
● KOOS. ● TSK-11. ● ACL-RSI.
MVIC = maximal voluntary isometric contraction (MVIC); KOS-ADLS = Knee Outcome Survey – Activities of Daily Living Scale; IKDC 2000 = International Knee Documentation Committee Subjective Knee Form (IKDC 2000); KOOS = Knee Injury and Osteoarthritis Outcome Score (KOOS); TSK-11 = Tampa Scale for Kinesiophobia; ACL-RSI = ACL-Return to Sport after Injury scale. Note . Based on the work of Fitzgerald, G. K., Axe, M. J., & Snyder-Mackler, L. (2000b). The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Physical Therapy, 80 (2), 128- 140.
RATE OF RETURNING TO THE PREINJURY ACTIVITY LEVEL
rate after nonoperative ACL management in Hurd’s study was at- tributed to the use of a screening exam to identify appropriate candidates and to the administration of a neuromuscular train - ing (Fitzgerald, Axe, & Snyder-Mackler, 2000a; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Hurd, Axe, & Snyder-Mackler, 2008a). When the decision for pursuing nonoperative ACL management to return to high-level activities was based on patient self-selec- tion, only 23% to 42% were able to resume high- level activities (Hughes & Watkins, 2006; Hurd, Axe, & Snyder-Mackler, 2008a). These findings highlight the importance of using a systematic screening exam for patient management following ACL injury. Performing ACL reconstruction does not ensure a return to par- ticipation in the same preinjury level of sport. The overall aver- age rate of return-to- sport activities after reconstructive surgery ranges between 44% and 92% (Ardern et al., 2012, 2011b; Ard- ern, Taylor, Feller, & Webster, 2014; Lai, Ardern, Feller, & Webster, 2017; Nawasreh et al., 2016). This wide range might have resulted from reporting the rate of return to sport for a wide spectrum of sport activities, levels of participation (recreational, competitive, preinjury activity level), patients’ ages, and different time points of following up. An updated systemic review and meta-analysis study reported that returning to any type of sport was as high as 81% after reconstructive surgery, while returning to the preinjury activity level of sport was 65% and to a competitive sport was 55% (Ardern, Taylor, et al., 2014). Other studies report that up to 65% of patients return to a competitive level of sport activities within the first 2 years of surgery, with only 38% of them main- taining their same sport level more than 2 years after the surgery (Ardern, Taylor, Feller, Webster, 2014; Brophy et al., 2012; Gobbi & Francisco, 2006; Langford et al., 2009). High rates of return to preinjury activity level (of 81% and 84% at 1 and 2 years, respec- tively) after surgery are reported in patients who meet the return- to-activity criteria before participating in their preinjury activity level (Nawasreh et al., 2016). The rate of return to preinjury sport activity has been reported for patients in different age groups. The rate of return to sport after surgery in adolescents was 92% (K. L. Dunn et al., 2016), high school age was 63%, and collegiate age was 69% (McCullough et al., 2012). Return to preinjury sport was also studied in elite athletes of dif- ferent sports. A systemic review and meta-analysis revealed that the pooled rate of return to sport in elite athletes is 83% (95% CI:
Although some individuals with ACL injury can return to unrestrict- ed functional activity without undergoing reconstruction surgery, many choose to modify their level of activity to less strenuous activities (Ageberg et al., 2008; Eitzen, Moksnes, Snyder-Mackler, Engebretsen, & Risberg., 2010; Fitzgerald, Axe, & Snyder-Mack- ler, 2000a; Moksnes & Risberg, 2009; Moksnes et al., 2008; Muai- di et al., 2007; Neeter et al., 2006; Tagesson et al., 2008) or need to undergo reconstructive surgery to return to preinjury activity levels (Logerstedt et al., 2010a). Of potential copers who received specialized neuromuscular training (perturbation training), 72% to 92% of them were success- ful in returning to preinjury activity level for a limited time (about 6 months) after injury without sustaining dynamic knee instability or modifying their activities (Fitzgerald, Axe, & Snyder-Mackler, 2000b; Hurd, Axe, & Snyder-Mackler, 2008a). A cohort study in- dicates that patients who opt for nonoperative management are more likely to return to level II sport activities in the first year and to level III sport activates in the second year after ACL injury, while patients who are managed operatively are more likely to return to participate in level I sport activities in the second year after sur - gery (Grindem, Eitzen, Engebretsen, Snyder-Mackler, & Risberg, 2014). The overall rate of returning to sport at 1 year from baseline test- ing for patients managed nonoperatively was 68.1%, with 54.8% of them participating in level I sport activities (Grindem et al., 2012). Preinjury activity level is correlated with the level of sport activity at 1 year after in patients with ACL injury who were man- aged nonoperatively. Patients who participated in level I sport ac- tivity prior to the injury demonstrated a lower rate of returning to sport when compared to those who participated in level II prior to the injury (Grindem et al., 2012). One study looked at the return- to-sport rate in adolescents who were managed nonoperatively and found that only 43.75% of adolescent patients returned to sport (K. L. Dunn, Lam, & Mcleod, 2016). Long-term outcomes following nonoperative management are mixed. A study by Kostogiannis and colleagues (2007) reported that only 42% of patients with ACL-deficient knees classified as potential copers were able to return to their preinjury activity level within 3 years after nonoperative ACL management. How- ever, Hurd and colleagues (2008a) indicated that 72% of potential copers had successfully returned to their preinjury activity level 10 years after nonoperative ACL management. The high success
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