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. 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 suggest waiting even longer (Nagelli & Hewett, 2017). In contrast, patients with ACL deficiency can begin participation in sport activities once they pass return-to-sport criteria. KNEE FUNCTIONAL OUTCOMES AFTER ACL INJURY AND RECONSTRUCTION SURGERY
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 management. 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 outcome 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 strength symmetry, demonstration of no joint Performance-based and patient-reported measures Most patients demonstrate dynamic knee instability, poor functional performance, and lowered perception of their knee function 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 after ACL injury (Fitzgerald, Axe, & Snyder- Mackler, 2000a; Fitzgerald, 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 function at 15 years (Kostogiannis et al., 2007; Moksnes & Risberg, 2009). Administering neuromuscular training and progressive quadriceps strength as part of nonoperative management resulted in positive short- and long-term effects on knee dynamic stability, knee functional performance, patient-reported knee function measures, and knee joint health (Chmielewski, Hurd, Rudolph, 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, & Risberg, 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 reported 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). Multiple 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. Early ACL reconstruction surgery has been advocated as the standard of care for youth athletes intending to return to pivoting and cutting sport activities (Marx et al., 2003; McRae, Chahal, Leiter, Marx, & MacDonald, 2011; Mirza, Mai, Kirkley, Fowler, & Amendola, 2000; Myklebust & Bahr, 2005).
effusion, and no reports of episodes of giving way or reinjury (Lynch et al., 2013). Successful outcomes following nonoperative or operative managements 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 after both non-operated and operated ACL management. Furthermore, the reconstruction surgery is often performed with the purpose of restoring passive knee stability to prevent damages to the joint surfaces and menisci and to preserve the joint health status (Marx et al., 2003). The time frame between ACL injury and surgical repair did not influence postoperative outcomes. Early reconstruction surgery resulted in clinical, functional, and patient-reported knee function outcome measures similar to those of the delayed surgery (Frobell et al., 2010; T. O. Smith et al., 2010). Furthermore, there were no differences between early or late surgery in regard to the postoperative complication, rate of return to sport, or incidence rates of radiographic knee osteoarthritis (Frobell et al., 2010; T. O. Smith et al., 2010). However, patients who participated in high preoperative activity level and underwent the reconstruction surgery within 3 months from surgery resumed a higher level of activity postoperatively (van Melick et al., 2016). Radiological signs of reconstructed knee osteoarthritis were reported 10 and 20 years after surgery in patients who reconstructed their injured ACL when they were adolescents (Mansson, Sernert, Rostgard-Christensen, & Kartus, 2015). Knee impairments and patients’ physical and psychological status prior to the surgery have been reported to be associated with postoperative patients’ functional recovery and outcomes (de Valk et al., 2013; Eitzen et al., 2009; Grindem et al., 2011; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012, 2013a; van Melick et al., 2016). Preoperative knee impairments related to ROM and quadriceps strength deficits contribute to significant knee complications after surgery (Cosgarea, Sebastianelli, & DeHaven, 1995; Mohtadi, Webster-Bogaert, & Fowler, 1991; Sachs, Daniel, Stone, & Garfein, 1989). Performing a reconstructive surgery on a patient with limited knee ROM is positively associated with the development of postoperative arthrofibrosis and patellofemoral problems (Cosgarea et al., 1995; Mohtadi et al., 1991; Sachs et al., 1989). Preoperative knee functional status is also predictive of the postoperative patient-reported and knee functional performance measures (de Valk et al., 2013; Eitzen et al., 2009; Grindem et al., 2011; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012, 2013a; van Melick et al., 2016). Preoperative quadriceps strength is predictive of knee function 2 years after surgery and has a positive effect on postoperative quadriceps at the time of return to activity (Lepley & Palmieri-Smith, 2016). Roewer and colleagues (2011) conducted a 2-year follow-up after surgery for a group of patients who received progressive quadriceps strength and neuromuscular perturbation training. They reported
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