include KOS-ADLS and GRS (Irrgang et al., 1998; Marx et al., 2001; Nyland, Cottrell, Harreld, & Caborn, 2006). Sport-specific patient-reported measures that assess the patients’ perception during participation in sport activities have been used as return- to-activity criteria after injury and surgery. Examples include IKDC 2000 and ACL- RSI (Gokeler et al., 2016; Hartigan, Zeni, Di Stasi, Axe, & Snyder-Mackler, 2012; Kong et al., 2012; Lentz et al., 2012; Nawasreh et al., 2016). Over the last decade, studies have highlighted the importance of the patients’ psychological readiness on functional recovery and decision to return to preinjury level of sport activities (Ardern, Taylor, Feller, & Webster, 2013; Everhart, Best, & Flanigan, 2013; te Wierike, et al., 2013). Approximately one-third of patients cite fear as a reason for not returning to sport (van Melick et al., 2021) and higher levels of fear are associated with second injury risk among those who do not necessarily meet objective functional criteria prior to returning to sport (Paterno et al., 2018). The interplay of psychological readiness to return to sport, objective functional performance, and other risk factors is likely highly complex. Further investigation is ongoing and warranted. Usually, patients start being tested on the return-to-activity criteria when they exceed the normal time frame for graft healing and once they have resolved the postoperative knee impairments related to the knee pain, effusion, ROM, and limping (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). Patients’ performance on strength and functional tests are often reported as the limb symmetry index to ensure normal limb-to-limb movement symmetry. Patients’ classification on return-to-activity criteria is strict. For patients to return to sport, they must achieve a high score exceeding specific cut-off value(s) identified for passing on each individual return-to-activity criterion (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). However, failing to achieve a high enough score to exceed the cut-off values on any of the criteria results in the patient being classified as failed. Patients who fail the return- to-activity criteria should be instructed on not returning to preinjury activity until they improve their knee functional performance and limb-to-limb symmetry (Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; White et al., 2013). Patients who pass the criteria may have limb-to-limb symmetry and functional knee performance that allow them to meet the demand of their sport activities. The cut-off value to determine patients’ readiness to return to sport based on functional performance and patient reported measures is debatable. A cut-off value of 90% has been used as an indication for achieving normal limb-to-limb movement symmetry and knee function to determine the moment to return-to-activity (Di Stasi et al., 2013; Grindem et al., 2016; Hartigan et al., 2010; Kyritsis et al., 2016; Nawasreh et al., 2016; Shelbourne & Klotz, 2006; Webster, Feller, & Hameister, 2001; White et al., 2013; Zwolski et al., 2016). For patients who are planning to return to pivoting and cutting sport activities, a cut-off of 100% on limb symmetry index is recommended (R. Thomeé et al., 2011). Postoperative performance on strength and functional measures may decrease from pre-operative levels in the contralateral (uninvolved) limb, so concurrent comparison to the contralateral limb should be interpreted cautiously (Wellsandt et al., 2017). It is important for clinicians to instruct the patients who pass the criteria to avoid immediately participating in their preinjury sport activities. Instead, patients should begin with lower- level sports participation in practice and gradually build up to competition while monitoring pain, effusion, and ROM before they fully return to preinjury activities (Fitzgerald, Axe, & Snyder-Mackler, 2000c; Capin, Behrns, et al., 2017; Batteries of tests can predict the risk for musculoskeletal injuries (Kiesel, Plisky, & Voight, 2007), classify individuals early after ACL injury (Fitzgerald, Axe, & Snyder-Mackler, 2000a), and identify important limb asymmetries after ACL injury and reconstruction (Gustavsson et al., 2006; Neeter et al., 2006). A battery of seven
strict return-to-activity criteria – including quadriceps strength testing, four single-legged hop tests, and two patient-reported questionnaires (see Table 6) – has been utilized to aid objective determination of return-to-sport readiness following ACL injury and reconstruction (Di Stasi et al., 2013; Fitzgerald, Axe, & Snyder-Mackler, 2000c; Hartigan et al., 2010; Nawasreh et al., 2016). Fitzgerald and colleagues (Piva, Fitzgerald, Delitto, Wisniewski, & Delitto, 2009) found that patients who returned to their preinjury activity level without reconstruction surgery achieved, on average, > 90% on all criteria that are similar to the ones reported in Table 6. Table 6: Return-to-Sport Criteria Patients must achieve 90% or more on: • Quadriceps strength index, • All 4 single-legged hop tests, • Knee Outcome Survey – Activity of Daily Living Scale, and 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; Hartigan 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 evaluated 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). • Global rating score of knee function. Note . From Western Schools, © 2018. A recent Norwegian cohort study indicated that 89% of patients returned to their preinjury level of activity within 2 years of reconstruction surgery. However, 38% of the patients who did return to preinjury level of activity without meeting the return-to- activity criteria (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). Another study conducted in Qatar reported that patients who did not meet the discharge criteria (isokinetic strength testing, running T test, and single-legged hop tests) before they returned to their sport activities possessed a risk four times higher for incurring ipsilateral graft injury compared to those who met
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