Håvard Moksnes

A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury

STUDY DESIGN Prospective cohort study without a control group. OBJECTIVES Firstly, to present our 5-week progressive exercise therapy program in the early stage after anterior cruciate ligament (ACL) injury. Secondly, to evaluate changes in knee function after completion of the program for patients with ACL injury in general and also when classified as potential copers or noncopers, and, finally, to examine potential adverse events. BACKGROUND Few studies concerning early-stage ACL rehabilitation protocols exist. Consequently, little is known about the tolerance for, and outcomes from, short-term exercise therapy programs in the early stage after injury. METHODS One-hundred patients were included in a 5-week progressive exercise therapy program, within 3 months after injury. Knee function before and after completion of the program was evaluated from isokinetic quadriceps and hamstrings muscle strength tests, 4 single-leg hop tests, 2 different self-assessment questionnaires, and a global rating of knee function. A 2-way mixed-model analysis of variance was conducted to evaluate changes from pretest to posttest for the limb symmetry index for muscle strength and single-leg hop tests, and the change in scores for the patient-reported questionnaires. In addition, absolute values and the standardized response mean for muscle strength and single-leg hop tests were calculated at pretest and posttest for the injured and uninjured limb. Adverse events during the 5-week period were recorded. RESULTS The progressive 5-week exercise therapy program led to significant improvements (P<.05) in knee function from pretest to posttest both for patients classified as potential copers and noncopers. Standardized response mean values for changes in muscle strength and single-leg hop performance from pretest to posttest for the injured limb were moderate to strong (0.49-0.84), indicating the observed improvements to be clinically relevant. Adverse events occurred in 3.9% of the patients. CONCLUSION Short-term progressive exercise therapy programs are well tolerated and should be incorporated in early-stage ACL rehabilitation, either to improve knee function before ACL reconstruction or as a first step in further nonoperative management. LEVEL OF EVIDENCE Therapy, level 2b.

Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study

Background Knee reinjury after ACL reconstruction is common and increases the risk of osteoarthritis. There is sparse evidence to guide return to sport (RTS) decisions in this population. Objectives To assess the relationship between knee reinjury after ACL reconstruction and (1) return to level I sports, (2) timing of RTS and (3) knee function prior to return. Methods 106 patients who participated in pivoting sports participated in this prospective 2-year cohort study. Sports participation and knee reinjury were recorded monthly. Knee function was assessed with the Knee Outcome Survey—Activities of Daily Living Scale, global rating scale of function, and quadriceps strength and hop test symmetry. Pass RTS criteria were defined as scores >90 on all tests, failure as failing any. Results Patients who returned to level I sports had a 4.32 (p=0.048) times higher reinjury rate than those who did not. The reinjury rate was significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed. 38.2% of those who failed RTS criteria suffered reinjuries versus 5.6% of those who passed (HR 0.16, p=0.075). More symmetrical quadriceps strength prior to return significantly reduced the knee reinjury rate. Conclusions Returning to level I sports after ACL reconstruction leads to a more than 4-fold increase in reinjury rates over 2 years. RTS 9 months or later after surgery and more symmetrical quadriceps strength prior to return substantially reduce the reinjury rate.

Single-Legged Hop Tests as Predictors of Self-Reported Knee Function in Nonoperatively Treated Individuals With Anterior Cruciate Ligament Injury

Background: Previous studies have found significant predictors for functional outcome after anterior cruciate ligament (ACL) reconstruction; however, studies examining predictors for functional outcome in nonoperatively treated individuals are lacking. Hypothesis: Single-legged hop tests predict self-reported knee function (International Knee Documentation Committee [IKDC] 2000) in nonoperatively treated ACL-injured individuals 1 year after baseline testing. Study Design: Cohort study (prognosis); Level of evidence, 2. Methods: Ninety-one nonoperatively treated patients with an ACL injury were tested using 4 single-legged hop tests on average 74 ± 30 days after injury in a prospective cohort study. Eighty-one patients (89%) completed the IKDC 2000 1 year later. Patients with an IKDC 2000 score equal to or higher than the age- and gender-specific 15th percentile score from previously published data on an uninjured population were classified as having self-reported function within normal ranges. Logistic regression analyses were performed to identify predictors of self-reported knee function. The area under the curve (AUC) from receiver operating characteristic curves was used as a measure of discriminative accuracy. Optimal limb symmetry index (LSI) cutoff for the best single-legged hop test was defined as the LSI with the highest product of sensitivity and specificity. Results: Single hop for distance symmetry indexes predicted self-reported knee function at the 1-year follow-up (P = .036). Combinations of any 2 hop tests (AUC = 0.64-0.71) did not give a higher discriminative accuracy than the single hop alone (AUC = 0.71). A cutoff of 88% (LSI) for the single hop revealed a sensitivity of 71.4% and a specificity of 71.7%. Conclusion: The single hop for distance (LSI) significantly predicted self-reported knee function after 1 year in nonoperatively treated ACL-injured patients. Combinations of 2 single-legged hop tests did not lead to higher discriminative accuracy than the single hop alone.

2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern

Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athletes return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

Performance-based functional evaluation of non-operative and operative treatment after anterior cruciate ligament injury.

Highly active anterior cruciate ligament (ACL)‐injured patients are usually recommended surgical treatment as the primary intervention. The objective of this study was to compare the functional outcome in a cohort of individuals after non‐operative treatment to individuals after surgical treatment at a 1‐year follow‐up. One hundred and twenty‐five subjects with a mean age of 27.2 years (±8.6 years), and participating in level I or II activities were included. Baseline and 1‐year follow‐up examination included four single‐legged hop tests, IKDC 2000, KOS‐ADLS, KT‐1000 knee arthrometer measurement, VAS, episodes of giving way, and activity level. Fifty‐one percent went through non‐operative treatment. Non‐operated subjects performed significantly better on two of the four single‐legged hop tests compared with the ACL‐reconstructed subjects at the 1‐year follow‐up. No other differences were observed. Both groups performed an average >90% compared with their uninjured leg on all single‐legged hop tests at the 1‐year follow‐up. The IKCD 2000 scores in the non‐operated and ACL‐reconstructed group were on average 86 and 87. ACL‐injured subjects should be informed of the possibility of success after non‐operative treatment, but future studies are needed to determine significant predictive factors for success for non‐operative and surgically treated individuals.

Prevalence and Incidence of New Meniscus and Cartilage Injuries After a Nonoperative Treatment Algorithm for ACL Tears in Skeletally Immature Children A Prospective MRI Study

Background: The increased risk of long-term osteoarthritis from concomitant injuries to the menisci or cartilage after an anterior cruciate ligament (ACL) injury in adults is well established. In skeletally immature children, ACL reconstruction is often recommended to reduce the risk of new intra-articular injuries. However, the prevalence and incidence of new injuries after nonoperative treatment of ACL injuries in children are unknown. Purpose: To prospectively investigate the incidence of new injuries to the menisci and joint cartilage in nonoperatively treated, skeletally immature children with a known ACL injury by use of bilateral 3.0-T MRI. Study Design: Case series; Level of evidence, 4. Methods: Forty skeletally immature children with a ruptured ACL (41 knees) followed a nonoperative treatment algorithm and were evaluated with bilateral 3.0-T MRI on 2 occasions (MRI1 and MRI2). The intra-articular structures were analyzed by 2 independent MRI radiologists. Monitoring of participation in physical activities was accomplished through a monthly online activity survey. Descriptive statistics and frequencies were extracted from the scoring forms and compared using the Fisher exact test. Results: Fourteen girls (35%) and 26 boys (65%) with a mean age of 11.0 ± 1.4 years at the time of injury were included. Time from injury to the final follow-up was 3.8 ± 1.4 years. Eighty-eight percent of the ACL-deficient children confirmed monthly participation in pivoting sports and/or in physical education classes in school. The prevalence of meniscus injuries in the 28 nonreconstructed knees was 28.5% at MRI1 and MRI2, and the incidence of new meniscus and cartilage injuries in the nonreconstructed knees from MRI1 to MRI2 was 3.6%. Thirteen children underwent ACL reconstruction, with a prevalence of meniscus procedures of 46.2%. The incidence of new meniscus injuries from diagnostic MRI to final follow-up was 19.5%. Surgical treatments for meniscus injuries were performed in 8 of the 41 knees. Conclusion: The incidence of new injuries to menisci and joint cartilage was low between MRI1 and MRI2 in the 28 nonreconstructed knees. Thirty-two percent of the knees required ACL reconstruction, and 19.5% required meniscus surgeries during the 3.8 ± 1.4 years of follow-up from injury. Further follow-up is needed to evaluate the long-term knee health in these children.

A Pair-Matched Comparison of Return to Pivoting Sports at 1 Year in Anterior Cruciate Ligament–Injured Patients After a Nonoperative Versus an Operative Treatment Course

Background: Patients usually return to pivoting sports between 6 months and 1 year after anterior cruciate ligament (ACL) reconstruction, but no matched study has so far examined 1-year return to sport rates in nonoperatively and operatively treated ACL-injured patients. Hypothesis: Anterior cruciate ligament-injured patients following a nonoperative treatment course, including recommendation of activity modification, will have lower return to pivoting sport rates than operatively treated patients 1 year after baseline testing/surgery, when matched by preinjury sports activity, age, and sex. Study Design: Cohort study; level of evidence, 3. Methods: Sixty-nine nonoperatively treated ACL-injured patients were pair-matched with 69 operatively treated patients (n = 138), based on specific preinjury sport, age, and sex. Nonoperatively treated patients were recommended not to return to level I sports. Patients were defined as nonoperatively or operatively treated according to their status at follow-up. The baseline and follow-up testing included registration of sports participation, KT-1000 arthrometer measurements, 4 hop tests, and patient-reported outcome measures. McNemars test and paired t tests or Wilcoxon test were used to compare outcomes of nonoperatively and operatively treated patients. Results: No significant baseline differences were found. At 12.9 ± 1.2 months (mean ± standard deviation) after baseline testing (nonoperative) and 12.7 ± 1.2 months after surgery (operative), there was no significant difference in overall return to sport rates (nonoperative: 68.1%, operative: 68.1%, P = 1.00), or in return to level I sport rates (nonoperative: 54.8%, operative: 61.9%, P = .66). Nonoperatively treated patients who participated in level I sports before injury had a significantly lower return to sport rate (54.8%) than nonoperatively treated patients who participated in level II sports (88.9%, P = .003). The nonoperatively treated patients had significantly higher knee joint laxity, but significantly better hop test limb symmetry indexes, Knee Outcome Survey Activities of Daily Living scores, and International Knee Documentation Committee Subjective Knee Form 2000 scores. None of the functional differences was larger than the smallest detectable difference. Conclusion: Anterior cruciate ligament-injured patients following a nonoperative treatment course, including recommendations of activity modifications, and operatively treated patients did not have significantly different rates of returning to pivoting sports after 1 year in this pair-matched cohort study. Clinicians should be aware of a potentially high level of noncompliance to recommendations of activity modifications. Although these results show that it is possible for nonoperatively treated patients to return to sport after rehabilitation, future follow-ups are needed to examine whether these patients maintain sports participation over time, and what long-term consequences they may suffer regarding subsequent injuries and knee osteoarthritis.

The Current Evidence for Treatment of ACL Injuries in Children Is Low A Systematic Review

BACKGROUND There is no consensus on the management of anterior cruciate ligament (ACL) injuries in skeletally immature children, and the methodological quality of published studies is questionable. The transphyseal reconstructions, physeal-sparing reconstructions, and nonoperative treatment algorithms that are advocated have little support in the literature. The purpose of this study was to systematically review the methodological quality of the literature on the management of ACL injuries in skeletally immature children. METHODS We performed a literature search with use of PubMed to identify prospective or retrospective studies whose primary aim was to assess the outcome after operative or nonoperative treatment of ACL injuries in skeletally immature children. To be included in the analysis, a study had to have a mean duration of follow-up of at least two years and a minimum of ten children in the study had to be verified to be skeletally immature. The methodological quality of the included studies was evaluated with use of the Coleman Methodology Score. RESULTS No randomized controlled trials, two prospective cohort studies, and twenty-nine retrospective studies met the inclusion criteria. The Coleman Methodology Score averaged 44.7 ± 9.2 out of 100 (range, 28 to 62). The methodological deficiencies were most evident with regard to the number of included children, the study design, and the description of rehabilitation protocols, outcome criteria, and outcome assessments. CONCLUSIONS Caution is necessary when interpreting the results of studies on the treatment of ACL injuries in skeletally immature children because of widespread methodological deficiencies. There is a need for appropriately sized prospective studies and detailed descriptions of rehabilitation programs.

Anterior Cruciate Ligament Injuries in Adolescents With Open Physis Effect of Recurrent Injury and Surgical Delay on Meniscal and Cartilage Injuries

Background: Treatment choices for skeletally immature patients sustaining anterior cruciate ligament (ACL) injuries have been controversial. The main dilemma is whether surgical treatment should be provided before patients reach skeletal maturity or whether nonoperative treatment should be provided until the physis has closed. Surgical reconstruction risks physeal damage, while delaying surgery may increase menisci and cartilage damage. Purpose: To identify patients at the onset of ACL injury and follow them longitudinally to surgery or final follow-up to describe differences between nonoperative and operative patients and to analyze the effect of delayed reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of patients enrolled at a large integrated health care system (IHS) between January 1, 2005, and December 31, 2008, was performed. The study sample included all females ≤12 years old and males ≤14 years old who were evaluated with an ACL injury. The incidence of ACL injuries in each age group was calculated using the number of covered lives by the IHS system per age category as the denominator. Each patient was longitudinally followed using an electronic health record that captures all patient encounters. Every encounter was reviewed for symptoms associated with the index knee, and encounters were considered significant if new-onset pain or swelling was reported. Patients were instructed to restrict their activities while awaiting skeletal maturity to undergo reconstruction by not participating in activities that included any cutting or pivoting movements that would risk injury to the knee. Cartilage and meniscal injuries were recorded for patients who underwent reconstruction. Results: A total of 71 patients were identified during the study period (66 males, 4 females). At the completion of this study, 47 (66.2%) patients had undergone ACL reconstruction, and 24 (33.8%) were being treated nonoperatively. While there were no significant associations between time to surgery and meniscal or cartilage injury, there was a positive association between the number of significant encounters and the likelihood of a combined cartilage and meniscal injury (P = .01). Conclusion: This is the first study to measure the incidence of ACL injuries in a skeletally immature population. For patients undergoing ACL reconstruction, an increased number of significant encounters was statistically significantly associated with combined meniscal and cartilage injuries, while increased time from injury to surgery was not significantly associated with additional injuries. In addition, one-third of the patients continued nonoperative treatment without symptoms that warranted surgical interventions during the follow-up period.

Functional outcomes following a non-operative treatment algorithm for anterior cruciate ligament injuries in skeletally immature children 12 years and younger. A prospective cohort with 2 years follow-up

Background The methodological quality of studies on treatment of anterior cruciate ligament (ACL) injuries in skeletally immature children after ACL injury is low, and no prospective studies have evaluated the functional outcomes following a non-operative treatment algorithm. Purpose To report changes in knee function and activity level in skeletally immature children following a non-operative treatment algorithm for a minimum of 2 years after ACL injury. Study design Prospective cohort. Methods 46 skeletally immature children aged 12 years and younger were evaluated at baseline and subsequent yearly follow-ups using patient-reported outcome measurements, isokinetic muscle strength measurements, single-legged hop tests and clinical examinations over a minimum period of 2 years. Participation in physical activities was monitored using a monthly online activity survey, and the main leisure-time sport activity was registered at the yearly follow-ups. Results 36 (78%) of the children did not undergo an ACL reconstruction during the follow-up. Statistically significant changes with questionable clinical relevance were discovered with the patient-reported outcome measurements or hop tests. Leg symmetry indexes were consistently above 90% for muscle strength and single legged hop tests throughout the study, and the isokinetic muscle strength improved significantly in the injured limb. Ninety-one per cent maintained participation in pivoting sports and/or physical education in school, although 38% of the ACL deficient children changed their main activity from a level 1 to a level 2 activity. Conclusions A non-operative treatment algorithm may be appropriate for ACL injured skeletally immature children, although a reduced participation in level 1 activities may be necessary for some children.