postoperative phase (more than 6 months after surgery; Lentz et al., 2012). The Knee Self-Efficacy Scale (K-SES) is a reliable instrument consisting of 22 items designed to measure how certain respondents are that they can perform various physical activities (P. Thomeé et al., 2006). K-SES scores are generally higher in males, individuals who have higher baseline physical activity levels, and younger individuals (P. Thomeé et al., 2007). Improvements in self-efficacy over the first 12 weeks following ACL reconstruction have been associated with improvements in pain and function during that same time frame (Chmielewski et al., 2011). Patients’ scores for self-efficacy of knee function preoperatively have also been shown to predict symptoms, muscle function, and return to acceptable levels of physical activity 1 year after ACL reconstruction (P. Thomeé et al., 2008). Activity scales Beyond patient self-report of general health and knee-specific impairment and function, activity scales provide further information regarding intensity and frequency of patient activity levels. The IKDC 2000 activity scale, as previously described, can be used to categorize patients according to sports or work demands (Daniel et al., 1994; Hefti et al., 1993). The Tegner Activity Level Scale is an 11-point grading scale for work and sports activities (Tegner & Lysholm, 1985). The scale rates activity level from 0 (sick leave or disability pension because of knee problems) to 10 (competitive sports such as soccer, football, or rugby at the national or elite level). The scale was initially developed to measure activity following knee ligamentous injury and has been validated for use following ACL injury. The Tegner Scale has demonstrated acceptable test-retest reliability (intraclass correlation coefficient = 0.80) after ACL
reconstruction and is sensitive to change up to 2 years following ACL reconstruction, with a minimally detectable change of 1 indicating true change in patient report (Briggs et al., 2009). The Marx Activity Rating Scale (Marx scale) is a four-item patient-report questionnaire that assesses the frequency of activities such as running, cutting, decelerating, and pivoting but is not intended to assess outcomes following intervention or surgery (Marx et al., 2001). The scale was developed to use in a population with a variety of knee disorders, but it is useful in the ACL population to assess whether patients have returned to preinjury activities at previous frequency levels. The Marx scale is scored from 0 to 16, with a score of 0 indicating completion of the four activity items less than one time per month and 16 indicating completion of the four activity items at least four times per week (Marx et al., 2001). The Marx scale is reliable and inversely correlated with age (Marx et al., 2001). It is important to select an outcome measure according to the construct it measures in relation to what information the therapist is attempting to gather. The IKDC 2000 is a more useful measure of knee impairment and function than the KOOS following ACL injury and reconstruction (van Meer et al., 2013). The ACL-RSI may be a more useful tool for measuring psychological influences on return-to-sport activities than the TSK-11 because it was developed specifically in relation to return to sport following ACL injury, whereas the TSK-11 was developed to assess pain- related fear of movement and reinjury not specific to the ACL population (Kvist et al., 2013). The SF-36 is an important measure to use in assessing a patient’s general health status and the comorbidities that may impact progress through rehabilitation following ACL injury or reconstruction.
DIFFERENTIAL DIAGNOSIS AND CONCOMITANT INJURIES
Injury to the ACL often occurs concomitantly with damage to other static knee joint structures, and differential diagnosis can be difficult. Meniscus (~50-65%), articular cartilage (~50%), and MCL pathology (~30%) commonly occur with ACL injuries. Incidence rates of injury to the PCL (1.4%) and lateral collateral ligament (LCL; 2.2%) with ACL injury is low, with these injuries usually resulting from traumatic events involving knee joint dislocation (Fanelli, Orcutt, & Edson, 2005; Majewski et al., 2006). Damage to the ACL, MCL, and medial meniscus can occur secondary to the common biomechanical positioning Medial collateral ligament Concomitant MCL injury (30.3%) is more common than LCL injury (2.2%) with ACL rupture (Majewski et al., 2006). Seventy- four percent of patients who sustain a complete tear to the MCL also sustain an ACL injury (Fetto & Marshall, 1978). MCL injuries are often treated nonoperatively regardless of severity and whether ACL reconstruction is performed. If ACL reconstruction is performed, it is typically postponed until the MCL has had the opportunity to heal, because valgus instability is detrimental Meniscus Meniscus injuries negatively affect patient-reported functional outcomes, with higher rates of knee arthrosis following ACL reconstruction compared to patients without meniscal damage (Cohen et al., 2007; Eitzen, Holm, & Risberg, 2009). Previous literature has reported that the odds of meniscus injury being present at the time of ACL reconstruction increase as time increases from initial injury (Fok & Yau, 2013; Granan, Bahr, Lie, & Engebretsen, 2009; O’Connor, Laughlin, & Woods, 2005), and the risk of secondary meniscal tear is reduced after ACL reconstruction (Kessler et al., 2008). However, no differences have been shown in rates of meniscal surgery with ACL reconstruction in patients who chose an early or delayed surgical date (Frobell et al., 2013). It is estimated that 50% to 65% of patients choosing ACL reconstruction demonstrate meniscal tears at the time of surgery (Granan et al., 2009; Magnussen et al., 2010; Majewski et al., 2006). Surgical resection
during ACL injuries, with excessive knee valgus and tibial internal rotation, which places increased tension on the MCL (Schein et al., 2012). Because the MCL is attached to the medial meniscus, it is also at increased risk of injury (Schein et al., 2012). However, the lateral meniscus is more likely to be injured in acute ACL injuries and in younger athletes, whereas the medial meniscus is more likely to be injured in chronic ACL-deficiency injuries and in older athletes (Kilcoyne, Dickens, Haniuk, Cameron, & Owens, 2012; Tandogan et al., 2004; Yeh, Starkey, Lombardo, Vitti, & Kharrazi, 2012). to optimal graft healing. Following ACL rupture, patients with grade III MCL injuries treated surgically demonstrate no difference in impairment-based or functional outcomes from those treated conservatively 2 years following injury (Halinen, Lindahl, Hirvensalo, & Santavirta, 2006). However, if chronic valgus instability is present following standard rehabilitation, surgical repair of the MCL may be warranted (Grant, Tannenbaum, Miller, & Bedi, 2012). (meniscectomy) followed by meniscus repair or observation only is the traditional and currently the most common approach in the United States used to treat meniscal injuries during ACL reconstruction (Magnussen et al., 2010). However, the frequency of surgical meniscal repair is expected to increase as a result of improving surgical techniques and increasing evidence of a higher risk of osteoarthritis following meniscectomy (Noyes & Barber-Westin, 2012). Indeed, Espejo-Reina and colleagues (2019) found in a study of over 2,000 patients that 55.6% of meniscal tears accompanied by ACL injuries were repairable. Herzog and colleagues (2018) reported that from 2002 to 2014, the rates of concomitant meniscus repairs with ACLR increased 73% while the rate of concomitant meniscectomy with ACLR increased only 34%, although meniscectomy remained the most common concomitant procedure. Concomitant meniscal injury, especially those treated by resection (meniscectomy), profoundly
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Book Code: PTNJ0824
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