that quadriceps strength continued to improve and most of gait kinematic and kinetic asymmetry resolved. Preoperative training also impacts postoperative function and biomechanical movement symmetry. Hartigan and colleagues found that administering progressive quadriceps strength and neuromuscular perturbation training prior to surgery improves limb-to-limb quadriceps strength and kinematic symmetries compared to abnormal kinematic asymmetries 6 months after surgery compared to administering only progressive quadriceps strength (Hartigan et al., 2009). Apparently, the preoperative patients’ status is crucial for better recovery and functional outcomes after surgery (de Valk et al., 2013; Eitzen et al., 2009; Lepley & Palmieri-Smith, 2016; Logerstedt et al., 2012; van Melick et al., 2016). This issue highlights the importance of incorporating rehabilitation training to specifically address patients’ impairments and restore a high level of knee functional performance prior to the reconstruction surgery. The effect of administering a preoperative rehabilitation program followed by a postoperative rehabilitation program has resulted in superior functional outcomes when compared to only administering a postoperative rehabilitation program (Failla et al., 2016; Grindem et al., 2015). Grindem and colleagues (2015) reported higher self-reported knee function in patients who received preoperative and postoperative rehabilitation programs compared to those who received only postoperative training. Failla and colleagues (2016) support these findings, as patients who received preoperative rehabilitation including perturbation and progressive quadriceps strength training and postoperative treatments demonstrated statistical and clinical improvements in their IKDC and KOOS scores and a higher rate of return to preinjury sport activities at 2 years after surgery compared to patients who underwent criterion-based post- operative rehabilitation alone (i.e., without additional, extended pre- operative rehabilitation training). Multiple variables contribute to better functional outcomes after surgery. Men achieve superior functional outcomes than women at 1 year follow- up after surgery, regardless of the graft type (van Melick et al., 2016). Use of allograft results in joint laxity and lower knee function outcomes (Hu, Qu, Xu, Zhou, & Lu, 2013; Kan et al., 2016; Zeng et al., 2016). Patients who receive a bone-patellar tendon-bone autograft may take longer to reach important clinical milestones than their counterparts with allograft or hamstring autograft (A. Smith et al., 2019). Younger patients return to a higher level of activities within 2 years after surgery compared to older patients. Tobacco consumption, high BMI, quadriceps weakness, and ROM deficit preoperatively have a negative effect on postoperative functional outcomes (de Valk et al., 2013; van Melick et al., 2016). Most studies investigating short-term knee functional outcomes report that the majority of patients improve after ACL reconstruction. Quadriceps strength and activation level has been shown to be lower in the involved limb compared to the non-involved limb and has been shown to persist up to 5 years after both ACL injury and reconstruction surgery (Hart et al., 2010; Petersen et al., 2014). Strength deficit in the reconstructed limb was reported to be between 27% and 39% for knee extensors and 16% and 35% for the knee flexors between 9 and 12 months after surgery. Additionally, impaired performance on counter movement jump and single hop for distance was reported to be 23% and 20% at the same follow- up time point (Larsen, Farup, Lind, & Dalgas, 2015). At 2 years after surgery, Logerstedt and colleagues have reported that normal limb symmetry index (LSI) related to quadriceps strength and single-legged hop performance is restored at 6 months and continues to improve 12 months after ACL reconstruction surgery (Logerstedt et al., 2012). Studies have shown that knee functional performance measured by single- limb hop tests improve at 6 to 12 months (Moksnes & Risberg, 2009) and continue to improve from 2 to 5 years after surgery (Ageberg et al., 2008; Hopper, Strauss, Boyle, & Bell, 2008). Scores on self-reported measures also continue to improve after ACL
reconstruction surgery. These outcomes are similar to findings reported in patients with ACL-deficient knees (Grindem et al., 2011; Moksnes & Risberg, 2009). A clinical review study reported that limb-to-limb strength deficits are, on average, 23% (range, 3% to 40%) and 14% (range, 3% to 28%) at 6 and 12 months, respectively, after reconstruction surgery (Lepley, 2015). Patients’ self-perceptions of knee function at 6 and 12 months after surgery are 14% and 13%, respectively, while limb symmetry indexes for hop performance are 11% at 6 months and 1.3% at 12 months after surgery (Lepley, 2015). The findings of this clinical review indicate limb-to-limb strength and patients’ self-reported deficits (more than 10%) continue to exist up to 12 months after surgery. (Note that findings among studies vary greatly, perhaps due to different training regimens as well as other factors.) The presence of these deficits might be detrimental at the time of returning to preinjury activities. E. H. Hartigan and colleagues (2010) indicated that individual limb-to-limb strength and hop performance deficits and patients’ self-reported knee function measures improved, on average, to less than 10% at 6 months after surgery. Only 5%, 48%, and 78% of patients score < 10% on a collective of seven objective measures (reported in Table 6) at 3, 6, and 12 months, respectively, after surgery (E. H. Hartigan et al., 2010). Nawasreh and colleagues (2016) reported that 49.5%, 42.5%, and 35% of patients demonstrated deficits more than 10% at objective measures reported in Table 7 at 6, 12, and 24 months, 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 activities. 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 incorporating 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 evaluation 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 • 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. ● KOS-ADLS. ● Global rating scale. ● IKDC 2000. ● 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.
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