increases the risk for osteoarthritis. Furthermore, movement patterns (i.e., gait biomechanics, including those associated with future osteoarthritis development) differ according to Articular cartilage Nearly 50% of ACL injuries also result in damage to the articular cartilage (Magnussen et al., 2010), and patients with articular cartilage lesions have an increased likelihood of meniscal injuries, and vice versa (Fok & Yau, 2013; Granan et al., 2009). For patients who undergo ACL reconstruction, older age and time from injury to surgery increase the odds of having cartilage lesions in the involved knee at the time of surgery (Fok & Yau, 2013; Granan et al., 2009; O’Connor et al., 2005). ACL injuries combined with articular cartilage damage are associated with Osteoarthritis Patients are at increased risk of knee osteoarthritis following ACL injury. Factors associated with early post-traumatic osteoarthritis include subsequent surgery, meniscal pathology (especially meniscectomy, and chondral injury (Claes et al., 2013; Jones & Spindler, 2017). Interestingly, there are no differences in the incidence of knee osteoarthritis whether early or delayed ACL reconstruction is chosen (Frobell et al., 2013). Although time from ACL injury to ACL reconstruction does not affect the incidence of osteoarthritis, rates of osteoarthritis may be comparable or higher in patients following ACL reconstruction compared to those who had nonoperative treatment (Luc et al., 2014; Wellsandt et al., 2018). Altered gait biomechanics are a suspected risk factor for the development and progression of knee osteoarthritis in the ACL population (Andriacchi & Mündermann, 2006; Butler,
concomitant medial meniscus treatment (Capin, Khandha, et al., 2019; Capin, Khandha, Zarzycki, Manal, et al., 2018).
complaints of more frequent and intense episodes of pain (Fok & Yau, 2013), along with poorer patient-reported outcomes (Kowalchuk et al., 2009). Cartilage debridement (chondroplasty) is the most common surgical technique employed during ACL reconstruction to treat cartilage lesions, but microfracture surgery and observation are also used (Magnussen et al., 2010). Microfracture surgery is a procedure in which small subchondral holes or fractures are created to stimulate cartilage repair (Mithoefer et al., 2005). Minick, Ferber, & Underwood, 2009; Webster, McClelland, Palazzolo, Santamaria, & 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; Wellsandt et al., 2016, 2020; Williams et al., 2021). Tibiofemoral joint 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 compared to those who do not (Wellsandt et al., 2016). Slower walking speed may also be associated with an early indicator of cartilage degeneration within the patellofemoral compartment of the knee (Capin et al., 2020) as well as blood biomarkers indicative of osteoarthritis (Pietrosimone et al., 2016).
MEDICAL DIAGNOSIS AND IMAGING
Diagnosis of an ACL injury can be made with reasonable certainty when a patient presents with clinical findings involving a mechanism 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 Lachman 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
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, clinical 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 examination when clinical diagnosis is indefinite.
OPERATIVE VERSUS NONOPERATIVE MANAGEMENT
The goal of rehabilitation or surgical management of ACL deficiency 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, depending 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 reconstructive 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 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 classification system has been developed to provide therapists with a tool to assist in decision making for patient education, management, and rehabilitation interventions.
CLASSIFICATION
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 clinicians 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 potential noncopers (Fitzgerald, Axe, & Snyder-Mackler, 2000a). Potential 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 developing 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 colleagues (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 copers if they demonstrate a single-legged 6-m timed hop index of 80% or higher between limbs, no more than
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