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Current perspectives of Australian therapists on rehabilitation and return to sport after anterior cruciate ligament reconstruction: A survey. Ebert JR, Webster KE, Edwards PK, Joss BK, D'Alessandro P, Janes G, Annear P. Phys Ther Sport. 2019 Jan;35:139-145. doi: 10.1016/j.ptsp.2018.12.004. Epub 2018 Dec 10.

Authors:
  • Perth Orthopaedic and Sports Medicine Centre, Perth ,Western Australia

Abstract

Abstract CONTEXT: The importance of rehabilitation and evaluation prior to return to sport (RTS) in patients undergoing anterior cruciate ligament reconstruction has been reported. OBJECTIVE: This study sought to investigate current perspectives of Australian orthopedic surgeons on rehabilitation and RTS evaluation. DESIGN: Survey. PARTICIPANTS: Members of the Australian Knee Society. MAIN OUTCOME MEASURES: A 14-question survey was disseminated to Australian Knee Society members (orthopedic surgeons) to investigate (1) preferred graft choice, (2) estimated retear rate, (3) importance of preoperative and postoperative rehabilitation, and (4) preferred timing of RTS and evaluation prior to RTS discharge. RESULTS: Of all 85 Australian Knee Society members contacted, 86% (n = 73) responded. Overall, 66 respondents (90.4%) preferentially used hamstring tendon autografts. All surgeons estimated their retear rate to be ≤15%, with 31 (42.5%) <5%. Twenty-eight surgeons (38.4%) reported no benefit in preoperative rehabilitation. The majority of surgeons (82.2%-94.5%) reported that postoperative rehabilitation was important within various periods throughout the postoperative timeline. Most surgeons did not permit RTS until ≥9 months (n = 56, 76.7%), with 17 (23.3%) allowing RTS between 6 and 9 months. The most highly reported considerations for RTS clearance were time (90.4%), functional capacity (90.4%), and strength (78.1%). Most commonly, knee strength and/or function was assessed via referral to a preferred rehabilitation specialist (50.7%) or with the surgeon at their practice (11.0%). CONCLUSIONS: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS evaluation. This is despite the current evidence demonstrating the benefit of preoperative and postoperative rehabilitation, as well as the emerging potential of RTS assessments consisting of strength and functional measures to reduce reinjury rates.
Original Research
Current perspectives of Australian therapists on rehabilitation and
return to sport after anterior cruciate ligament reconstruction:
A survey
Jay R. Ebert
a
,
b
,
*
, Kate E. Webster
c
, Peter K. Edwards
a
,
b
, Brendan K. Joss
b
,
Peter D'Alessandro
d
, Greg Janes
e
, Peter Annear
e
a
School of Human Sciences (Exercise and Sport Science), University of Western Australia, Crawley, Western Australia, Australia
b
HFRC Rehabilitation Clinic, Nedlands, Western Australia, Australia
c
School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
d
Coastal Orthopaedics, Bethesda Hospital, Claremont, Western Australia, Australia
e
Perth Orthopaedic and Sports Medicine Centre, West Perth, Western Australia, Australia
article info
Article history:
Received 2 August 2018
Received in revised form
7 December 2018
Accepted 8 December 2018
Keywords:
Anterior cruciate ligament reconstruction
Rehabilitation
Physical therapy
Return to sport
abstract
Objectives: To investigate views and practices of Australian therapists on rehabilitation and return to
sport (RTS) after anterior cruciate ligament reconstruction (ACLR).
Design: Survey-based study.
Setting: Online survey platform.
Participants: Australian Physiotherapists and Accredited Exercise Physiologists (n ¼223).
Main outcome measures: 1) perceived benet, timing and frequency of rehabilitation, 2) timing of RTS
and information on RTS evaluation and discharge criteria.
Results: Therapists preferred to consult patients for the rst time at 1e4 days (27.8%), 7 days (25.6%) or
7e14 days (30.5%) post-surgery. Within the rst 6 weeks, 82.1% of therapists preferred patient visitation
1e2 times per week. Between 3 and 6 months, therapists mainly recommended less frequent visitation
with a focus on home exercises. While 22.0% and 53.8% of therapists were willing to discharge patients
for sport at 6e9 and 9e12 months, respectively, 22.9% preferred 12e18 months. Common RTS consid-
erations were functional capacity (98.7%), strength (87.0%), lower limb and trunk mechanics (96.0%) and
psychological readiness (87.9%). Knee strength was evaluated via manual muscle testing (33.0%), hand
held (26.7%) and isokinetic (11.8%) dynamometry. For functional evaluation, 84.3% of therapists employed
a hop battery (2 hop tests).
Conclusions: This survey revealed variation in beliefs and practices surrounding rehabilitation and RTS
evaluation in Australian therapists.
©2018 Elsevier Ltd. All rights reserved.
1. Introduction
Anterior cruciate ligament (ACL) ruptures are common, partic-
ularly during sports involving cutting, landing and pivoting
movements, with a reported annual incidence of 68.6 per 100,000
person-years (Sanders et al., 2016). Surgical ACL reconstruction
(ACLR) is currently considered the standard clinical treatment
(Shea et al., 2015), and a recent study reported that Australia has
the highest incidence of ACLR in the world (Zbrojkiewicz, Vertullo,
&Grayson, 2018). This study reported a 43% annual increase in the
incidence of ACLR between 2000 and 2015 from 54.0 to 77.4 (per
100,000 population), and by 74% in patients under 25 years from
52.6 to 91.4 (Zbrojkiewicz et al., 2018). The primary goals of ACLR
are to maximise knee stability and functional capacity, whilst
permitting a safe return to sport (RTS) (Ardern, Webster, Taylor, &
Feller, 2011;Barber-Westin &Noyes, 2011), though a recent sys-
tematic review and meta analysis reported an overall secondary
ACL injury rate of 15% (7% incidence on the ipsilateral side) with a
21% re-injury rate (10% incidence on the ipsilateral side) in those
under 25 years (Wiggins et al., 2016).
*Corresponding author. School of Human Sciences (M408), The University of
Western Australia, 35 Stirling Highway, Crawley, 6009, Western Australia, Australia.
E-mail address: jay.ebert@uwa.edu.au (J.R. Ebert).
Contents lists available at ScienceDirect
Physical Therapy in Sport
journal homepage: www.elsevier.com/ptsp
https://doi.org/10.1016/j.ptsp.2018.12.004
1466-853X/©2018 Elsevier Ltd. All rights reserved.
Physical Therapy in Sport 35 (2019) 139e145
A consensus statement in 2016 reports a RTS continuum
following injury or surgery, inclusive of: 1) return to participation
(return to training though not yet deemed medically, physically or
psychologically ready to return to RTS), 2) RTS (returned to the
dened sport inclusive of games) and 3) return to performance
(playing and performing at or above pre-injury level) (Ardern et al.,
2016). A range of variables may inuence the patient's ability and
readiness to RTS, as well as their re-injury risk, including pre-
operative (age, pre-operative rehabilitation, knee extension and
neuromuscular control), intra-operative (graft choice) and post-
operative (rehabilitation and psychological factors) factors
(Irarr
azaval, Kurosaka, Cohen, &Fu, 2016). Pre-operative rehabili-
tation aims to address musculoskeletal and range of motion de-
cits, as well as better prepare the patient physically and mentally
for the surgical process, and a number of studies and reviews have
demonstrated its positive effect on post-operative knee function
and muscle strength (Alshewaier, Yeowell, &Fatoye, 2017;Eitzen,
Holm, &Risberg, 2009;Eitzen, Moksnes, Snyder-Mackler, &Ris-
berg, 2010;Failla et al., 2016;Grindem et al., 2015;Shaarani et al.,
2013). Post-operative rehabilitation aims to address decits in
neuromuscular strength and limb loading strategies, which are
suggested to be key components for reducing the risk of secondary
injury (Paterno et al., 2010). A recent systematic review and
multidisciplinary consensus has summarised the components of
rehabilitation (van Melick et al., 2016), and a comprehensive test
battery should also be employed in all patients prior to clearance
for RTS (van Melick et al., 2016). The potential value of these test
batteries has been demonstrated, with the emerging link between
lower limb strength/functional asymmetry and an increased re-
injury risk (Grindem, Snyder-Mackler, Moksnes, Engebretsen, &
Risberg, 2016;Kyritsis, Bahr, Landreau, Miladi, &Witvrouw, 2016).
Several studies and reviews have been published over the last
5e10 years highlighting the importance and components of pre-
and post-operative rehabilitation (Alshewaier et al., 2017;Eitzen
et al., 2009,2010;Failla et al., 2016;Grindem et al., 2015;Paterno
et al., 2010;Shaarani et al., 2013;van Melick et al., 2016), as well
as RTS testing prior to patient discharge (Grindem et al., 2016;
Kyritsis et al., 2016;van Melick et al., 2016), though it is not known
whether this evidence is being adopted by therapists who work
with these patients to achieve their RTS goals. Therefore, this study
sought to investigate current practice of Australian therapists on
pre- and post-operative rehabilitation, as well as RTS discharge
criteria and methods employed in evaluating patients prior to RTS.
2. Methods
A 15-item survey was developed upon discussion and collabo-
ration between a group of Australian Physiotherapists, Accredited
Exercises Physiologists (AEPs), orthopaedic surgeons and university
academics, all with a clinical interest in ACLR and/or a focus in
musculoskeletal and orthopaedic research. The survey was anon-
ymous and this was made clear to respondents, with no identifying
information collected. As an introduction to the survey, it was
stated to respondents that the survey had been developed only for
therapists actively working with patients before and after ACLR,
irrespective of whether they were working with one patient or
many on an annual basis. Respondents were asked to answer the
survey questions based on their current practice with their ACLR
patients. It was also clearly stated that if therapists were not
working with these patients, they should not complete the survey.
Upon development and internal administration of the survey, it
was estimated and communicated to respondents that it would
require 10 min to complete.
The survey questions and response items are shown in Table 1.
In addition to basic respondent demographics and primary practice
area (items 1e3), the survey sought to investigate information on
the preferred post-operative timing and frequency of rehabilitation
(items 4e6), current views on the importance of pre- (item 7) and
post-operative (items 8e11) rehabilitation, timing of RTS discharge
(item 12) and information on discharge criteria and methods of RTS
and/or physical evaluation (items 13e15). A categorical response
was sought for each question and only one item could be selected,
apart from item 13 (RTS discharge criteria), item 14 (methods
adopted to evaluate knee strength) and item 15 (methods adopted
to evaluate lower limb functional capacity).
The survey was constructed and disseminated via an online
platform (Survey Monkey), with a link to the survey provided to all
members of the Australian Physiotherapy Association (APA) and
Exercise and Sport Science Australia (ESSA). The APA is the peak
member body representing Australian Physiotherapists, and ESSA
is the peak member body representing Australian AEPs. The study
information and survey link was made available via several avenues
to members in both disciplines between February and June 2018,
including the respective Members portals and of both groups, and
State and National electronic news bulletins, in order to maximise
survey exposure.
Following survey closure, the online platform permitted export
of group and individual responses in Microsoft Excel format, where
data could then be analysed. The percentage of respondents
selecting each response within the 15 survey questions was tabu-
lated. Further exploration was made into items that provided the
option other (please specify), to investigate other avenues that
were being employed by therapists in clinical practice.
3. Results
A total of 223 therapists responded to the survey, with all survey
items being completed by all respondents. Of the participant group,
84.8% (n ¼189) had a clinical focus treating all musculoskeletal
conditions, with 10.8% (n ¼24) stating that their focus was specif-
ically in the lower limb (Table 1). The majority (55.2%) of re-
spondents estimated they worked with 6e20 ACLR patients
annually, though 26% worked with 1e5,15.7% with 20e50 and 3.1%
with >51 patients each year (Table 1). All Australian geographical
locations were represented (Table 1).
The majority of therapists expressed a desire to consult their
patients for the rst time following hospital discharge at 1e4 days
(27.8%), 7 days (25.6%) or 7e14 days (30.5%) post-surgery, with a
further 15.3% of therapists stating once the surgeon had cleared the
patient to initiate out-patient rehabilitation (Table 1). As expected,
the majority of therapists (95.5%) felt that pre-operative rehabili-
tation was important or essential for patients embarking on ACLR
(Table 1), which was also the case for post-operative rehabilitation
within the rst 6 post-operative weeks (99.1%), within 6 weeks to 3
months (100%), within 3e6 months (99.5%) and from 6 months
onwards (96.4%) (Table 1). However, the recommended frequency
of rehabilitation visits varied, with visits twice per week (42.6%),
once per week (39.5%) and once every two weeks (12.1%) reported
most commonly within the rst six post-operative weeks (Table 1).
Between 3 and 6 months post-surgery, most therapists recom-
mended less frequent visitation with a focus on home (or gym)
based exercises with periodic review (40.4%), though 25.5% of
therapists still recommended supervised visitation once or twice
per week.
Providing individual discharge criteria were met, the majority of
therapists (53.8%) were willing to discharge a patient for RTS at
9e12 months post-surgery (Table 1). However, 22.0% of therapists
were willing to discharge patients at 6e9 months, with 22.9%
waiting until 12e18 months (Table 1).
For RTS clearance, the most highly reported considerations were
J.R. Ebert et al. / Physical Therapy in Sport 35 (2019) 139e145140
Table 1
Responses (n, %) for each question within the 15-item anonymous survey provided to therapists.
Item Question/Response n % Item Question/Response n %
1 What is your primary area of expertise for the purpose of this survey? 2 Approximately, how many ACLR patients would you see per year?
All musculoskeletal conditions (including orthopaedics) 189 84.8% 1e5 58 26.0%
Primarily lower limb 24 10.8% 6e20 123 55.2%
Primarily upper limb 0 0.0% 21e50 35 15.7%
Other sub-specialty, but I still see some ACLR patients 10 4.5% >51 7 3.1%
Other (please specify) 0 0.0%
3 Which state or territory do you practice in? 4 At what post-operative time-point do you encourage your patient to be seen by you
after their ACLR surgery?
ACT 7 3.1% Within the rst 1e4 days after surgery 62 27.8%
NSW 70 31.4% Within the rst 7 days after surgery 57 25.6%
NT 2 0.9% Between 1 and 2 weeks after surgery 68 30.5%
SA 16 7.2% After being cleared by their surgeon 34 15.3%
TAS 3 1.4% When they feel ready to start, though I do not recommend a specic (or
ideal) time
2 0.9%
WA 37 16.6%
VIC 48 21.5%
QLD 40 17.9%
5 How often would you like to see your ACLR patient for supervised
rehabilitation (within the rst 6 weeks post-surgery)?
6 Between 3 and 6 months post-surgery, how often would you like to see your ACLR
patient within your practice?
Twice per week 95 42.6% Twice per week 19 8.5%
Once per week 88 39.5% Once per week 38 17.0%
Once every two weeks 27 12.1% Once every two weeks 74 33.2%
Less frequently if possible, with a focus on home-based
exercises and periodic review
11 4.9% Less frequently if possible, with a focus on home (or gym) based exercises
and periodic review
90 40.4%
Other (please specify) 2 0.9% Other (please specify) 2 0.9%
7 How important do you think pre-operative rehabilitationis to post-
operative patient outcome?
8 How important do you think post-operative rehabilitationis to overall patient
outcome within the rst 6 weeks post-surgery?
Essential 124 55.6% Essential 177 79.4%
Important 89 39.9% Important 44 19.7%
Not important 5 2.2% Not important 2 0.9%
No view or opinion 5 2.2% No view or opinion 0 0.0%
9 How important do you think post-operative rehabilitationis to overall
patient outcome within 6 weeks to 3 months post-surgery?
10 How important do you think post-operative rehabilitationis to overall patient
outcome within 3e6 months post-surgery?
Essential 188 84.3% Essential 157 70.4%
Important 35 15.7% Important 65 29.2%
Not important 0 0.0% Not important 1 0.5%
No view or opinion 0 0.0% No view or opinion 0 0.0%
11 How important do you think post-operative rehabilitationis to overall
patient outcome from 6 months post-surgery onwards?
12 Providing you are satised with their progress and physical capacity, what time do you
typically permit a patient to return to sport (including AFL, rugby, soccer, netball,
hockey etc.)?
Essential 109 48.9% 6e9 months 49 22.0%
Important 106 47.5% 9e12 months 120 53.8%
Not important 8 3.6% 12e18 months 51 22.9%
No view or opinion 0 0.0% 18 months 2 0.9%
I tell them they should not return to higher demand sports (e.g. AFL, rugby,
soccer, netball)
1 0.5%
13 Given the aforementioned high demand sports, what factors
do you personally consider before clearinga patient to
return to their sport
14 If you consider knee strengthto be important prior to clearing a patient to return to
their sport, how do you evaluate this?
Time from surgery 175 78.5% I use manual muscle testing methods 73 33.0%
Age of the patient 120 53.8% I use hand held dynamometry 59 26.7%
Knee Range of Movement and/or Laxity 155 69.5% I use an isokinetic dynamometer 26 11.8%
Side-to-side differences in muscular size (i.e. thigh girth) 122 54.7% I extrapolate/estimate knee strength from other measures such as hop
capacity
108 48.9%
Patient-reported Outcome Questionnaires 102 45.7% I do not consider these tests that important 1 0.5%
Psychological readiness (e.g. condence, anxiety) 196 87.9% I feel strength is important, but do not have access to necessary equipment
(and/or do not feel manual testing methods are accurate enough) so I refer
on to someone who can provide such an evaluation for me
24 10.9%
Knee Strength 194 87.0%
Functional capacity (e.g. jump and/or hop tests) 220 98.7%
Lower limb and trunk mechanics during jumping/landing
tasks
214 96.0%
Other (please specify) 45 20.2% Other (please specify) 25 11.2%
15 If you consider lower limb functional capacityto be important prior to
clearing a patient to return to their sport, how do you evaluate this?
Single limb hop for distance 11 4.9%
6 m timed hop test 1 0.5%
Triple hop for distance 8 3.6%
Triple crossover hop for distance 1 0.5%
A hop test battery (including 2 of the 6 m timed and single,
triple hop and triple crossover hops for distance)
188 84.3%
Single limb vertical hop 97 43.5%
Star excursion and/or Y-balance test 140 62.8%
I do not consider these tests that important 2 0.9%
Other (please specify) 48 21.5%
J.R. Ebert et al. / Physical Therapy in Sport 35 (2019) 139e145 141
functional capacity (98.7%) and knee strength (87.0%), lower limb
and trunk mechanics during jumping/landing tasks (96.0%), psy-
chological readiness (87.9%) and time from surgery (78.5%)
(Table 1). Of those that also selected the other (please specify)
option, the most common additional responses included the suc-
cessful navigation of sport specic drills and training scenarios
(relevant to their sport) (n ¼20), as well as agility and change of
direction tasks (n ¼10), with hip strength (n ¼3), proprioception
(n ¼3) and effusion (n ¼3) also reported.
For evaluation of lower limb (or knee) muscular strength, a va-
riety of methods were employed including manual muscle testing
methods (33.0%), hand held dynamometry (26.7%) and isokinetic
dynamometry (11.8%); with 48.9% of therapists also stating that
they extrapolate or estimate strength from other measures such as
hop capacity (Table 1). Of those that also selected the other (please
specify)option, the most common additional responses included
single leg squat capacity and/or endurance (n ¼10), and 1, 3 and/or
5RM measures of strength during tasks such as a single leg press,
squat, single leg bridge and calf raise.
For evaluation of lower limb functional capacity, 84.3% of ther-
apists employed a hop test battery consisting of at least two of the
following tests: 6 m timed hop and the single, triple and triple
crossover hop tests for distance, while 9.5% of therapists utilised
only one of the aforementioned hop tests (Table 1). A single leg
vertical hop (43.5%), or the star excursion balance test (SEBT) and/
or Y-balance test (YBT) (62.8%) were also commonly reported
(Table 1). Of those that also selected the other (please specify)
option, the most common additional responses included tests of
agility such as the T-test or Figure 8 (n ¼22), an evaluation of
running dynamics and/or full pace sprinting with acceleration/
deceleration tasks (n ¼6), and lateral and/or medial hop tests
(n ¼4).
4. Discussion
This cross sectional survey disseminated to Australian Physio-
therapists and AEPs, working with patients before and after ACLR,
revealed differences within this group regarding current views and
adopted practices with respect to rehabilitation and RTS. A range of
preferred times to begin the out-patient rehabilitation process
were outlined by therapists, with a similar distribution of re-
spondents across 1e4 days, 7 days and 7e14 days post-surgery.
Evidence-based and clinical reviews on ACLR rehabilitation often
specify a range of early activities that are initiated in the rst post-
operative week (Adams, Logerstedt, Hunter-Giordano, Axe, &
Snyder-Mackler, 2012;Wilk &Arrigo, 2017), many of which are not
provided to patients prior to their hospital discharge. These exer-
cises link with the early post-operative goals and, given the
importance of early swelling control, patella mobility, quality
quadriceps activation and near-normal ambulation, as well as
restoring good knee range of motion (extension and exion)
(Adams et al., 2012;Wilk &Arrigo, 2017), then good rationale exists
for an immediate start to the out-patient rehabilitation process
within the rst post-operative week. A recent multidisciplinary
consensus recommended an immediate start to rehabilitation after
ACLR (van Melick et al., 2016), though an optimal start time has not
been proposed. At the same time, this may also be inuenced by
concomitant surgeries and specic surgeon guidelines (in the cur-
rent study, 15% of therapists stated they would begin post-
operatively once the surgeon had cleared the patient to do so), so
good communication between the surgeon and therapist is
essential (van Melick et al., 2016).
Variation existed amongst therapists as to the frequency of pa-
tient visitation they preferred, albeit the actual visitation frequency
may depend on a range of factors including practice location and
cost. It was interesting that within the rst six post-operative
weeks, a period in which almost 80% of therapists stated that
rehabilitation was essential(with a further 20% stating it as
important), approximately 40% of therapists each preferred once or
twice weekly visitation, with a further 12% opting for once every
two weeks. Again, this is multi-factorial and typical customs of the
rehabilitation practice and individual patient progression may alter
these perspectives, though there is no consensus on the optimal
amount of supervised sessions per week, or total sessions over the
initial six week period. From 3 months post-surgery, almost 26% of
therapists still preferred supervised visitation once her twice per
week, with more than 40% of therapists at that stage recom-
mending less frequent review with a patient transition toward
home (or gym) based independent rehabilitation. Alternatively,
while Physiotherapists and AEPs often work with patients
throughout these end-stage and sport-specic conditioning phases
of rehabilitation, another factor that could alter the recommended
frequency of visitation is referral of the patient by an individual
therapist to a personal trainer or strength and conditioning coach
for late-stage rehabilitation. It is important that patients take some
ownership of their own rehabilitation from this time, though pe-
riodic review and progression is still advocated (van Melick et al.,
2016). Nonetheless, a systematic review in 2012 demonstrated
that home-based rehabilitation with minimal therapist involve-
ment may be effective (based on the laxity, strength and patient-
reported outcome measures evaluated), particularly in a moti-
vated patient (Kruse, Gray, &Wright, 2012).
As expected, the vast majority of therapists stated that post-
operative rehabilitation was important (or essential) at different
stages throughout the recovery timeline up until (and beyond) 6
months post-surgery. However, a growing body of evidence exists
supporting the positive effect of pre-operative rehabilitation on
post-operative outcome (Alshewaier et al., 2017;Eitzen et al., 2009,
2010;Failla et al., 2016;Grindem et al., 2015;Shaarani et al., 2013),
and it was encouraging to note that the majority of therapists
(95.5%) felt that pre-operative rehabilitation was important or
essential. However, this survey did not proceed to investigate the
percentage of patients that actually do embark on a pre-operative
program prior to their surgical procedure. Some institutions
recommend a progressive pre-operative rehabilitation period (of at
least 5 weeks) in patients who have suffered an acute ACL tear
(Grindem et al., 2015), with the rationale that improved pre-
operative knee function will enhance post-operative outcome
should surgery eventuate. Furthermore, recent research suggests
that many patients may be successful with non-surgical treatment
(Grindem, Wellsandt, Failla, Snyder-Mackler, &Risberg, 2018).
However, it has been reported that Australia has the highest inci-
dence of ACLR in the world (Zbrojkiewicz et al., 2018), and anec-
dotally a common mindset of Australian patients and surgeons is to
proceed quickly toward surgery following injury, with many
viewing their own RTS timeline as beginning from day of surgery,
rather than the injury. Furthermore, the additional patient cost
associated with pre-operative rehabilitation may be a deterring
factor from the surgeon referring for pre-operative management.
The method employed for evaluating physical strength and/or
function varied. Overall, approximately 84% of therapists employed
a hop test battery consisting of at least two of 6 m timed hop and
the single, triple and triple crossover hop tests for distance. These
four hop measures were rst published in the form of a 4-hop test
battery (Noyes, Barber, &Mangine, 1991), and are reliable and easy
to administer (Logerstedt et al., 2012;Noyes et al., 1991). Other
commonly employed functional measures included a single leg
vertical hop and/or the SEBT (or YBT). These tests are also easy to
perform in a clinical setting and reduced performance in the YBT
has been observed in patients after ACLR (Clagg, Paterno, Hewett, &
J.R. Ebert et al. / Physical Therapy in Sport 35 (2019) 139e145142
Schmitt, 2015), while an association between SEBT decits and
non-contact knee injuries has been reported (Stifer et al., 2017).
Isokinetic dynamometry may be gold standard in quadriceps
and hamstrings evaluation, and forms part of the current evidence-
based testing batteries that have highlighted an association be-
tween side-to-side strength decits and re-injury risk (Grindem
et al., 2016;Kyritsis et al., 2016), though this was only employed
by 12% of therapists likely due to cost and availability. Manual
muscle testing methods (33%) and hand held dynamometry (27%)
were also employed, though while it has been demonstrated that
hand held dynamometry can be used to quantify quadriceps
strength in a clinic setting should more specialised equipment not
be available, caution must be employed as they may overestimate
quadriceps strength side-to-side symmetry (Sinacore et al., 2017).
Interestingly, a recent survey amongst physical therapists of the
American Physical Therapy Association (APTA) reported that 56% of
therapists used manual muscle testing as their only method of
strength evaluation (Greenberg, Greenberg, Albaugh, Storey, &
Ganley, 2018). Furthermore, the current study demonstrated that
almost 50% of therapists stated that they extrapolate or estimate
knee strength from other functional measures such as hop capacity.
Caution must also be employed in this situation. Toole et al.
demonstrated that in a cohort of young athletes cleared for sport
participation after ACLR, approximately 70% of patients presented
with a limb symmetry index (operated limb as a percentage of the
non-operated limb) 90% for each of the 6 m timed hop and single,
triple and triple crossover hop tests for distance (Toole et al., 2017).
However, approximately 40% of patients met the 90% limb sym-
metry index for peak isokinetic quadriceps strength (Toole et al.,
2017). In other recent studies, Welling et al. reported that only
3.2% and 11.3%of patients passed all criteria at 6 and 9 months post-
surgery, respectively, inclusive of functional hop testing (6 months,
62.9% passed; 9 months, 77.4% passed), and peak isokinetic knee
dynamometry (6 months, 8.1% passed; 9 months, 21.0% passed)
(Welling et al., 2018). Furthermore, Ebert et al. showed that in ACLR
patients assessed at 10e14 months post-surgery, 47e58% of pa-
tients had a limb symmetry index 90% for the four aforemen-
tioned hop tests, though only 31% had a peak isokinetic quadriceps
strength limb symmetry index 90% (Ebert et al., 2017). In sum-
mary, it is clear that strength and functional tests do not necessarily
align with each and should be combined in the form of a compre-
hensive physical test battery, while it is advisable that isokinetic
dynamometry be employed if possible, and patients referred to an
institution with the relevant facilities if appropriate.
Variation also existed within the permitted timing of RTS. RTS is
largely criterion based (Dingenen &Gokeler, 2017), and providing
all discharge criteria were met approximately 50% of therapists
were willing to discharge their patients between 9 and 12 months
after surgery. However, 22% of therapists were still satised with an
earlier discharge (6e9 months). This may also depend on other
factors (outside of passing all individual therapist discharge
criteria) such as the professional level of the athlete and require-
ment to play earlier, though research has reported a reduced re-
injury rate for all knee injuries if RTS is delayed until 9 months
following ACLR (Grindem et al., 2016). Furthermore, 23% of thera-
pists did not permit RTS until 12e18 months. A 24-month RTS
timeline has previously been proposed (Nagelli &Hewett, 2016),
taking into account the process of ligament revascularisation and
maturation, the restoration of proprioceptive and neuromuscular
decits, overall knee joint health, and of course the high incidence
of ACL re-injuries that have been reported (Kyritsis et al., 2016;
Paterno, Rauh, Schmitt, Ford, &Hewett, 2012;Salmon, Russell,
Musgrove, Pinczewski, &Refshauge, 2005;Shelbourne, Benner, &
Gray, 2014). The challenge for the therapist (and surgeon) is
educating the patient on the importance of rehabilitation and a
delayed RTS, who is otherwise keen to return irrespective of the
existing evidence.
For RTS clearance, time from surgery was still reported
commonly, as was functional capacity and strength, as well as
lower limb and trunk mechanics during landing tasks. When
employing functional hop and muscular strength (in particular
quadriceps strength) measures as part of a RTS test battery, some
research has demonstrated and increased re-injury risk in patients
not meeting side-to-side limb symmetry scores of 90% (operated
versus non-operated limb) (Grindem et al., 2016;Kyritsis et al.,
2016). Furthermore, research has highlighted the altered landing
strategies that can present after ACLR, as well as the link between
certain biomechanical decits and ACL injury risk (Hart et al., 2016;
Johnston, McClelland, &Webster, 2018;Pappas, Shiyko, Ford, Myer,
&Hewett, 2016;Trigsted, Post, &Bell, 2017). Patient-reported
psychological readiness was also commonly reported and, while
the method of evaluating psychological readiness was not evalu-
ated in the current study and its effect on re-injury has not been
assessed, its positive association with a higher perceived func-
tioning knee and returning to pre-injury activity levels has been
reported (Ardern et al., 2014). A number of factors have also been
identied that may affect psychological readiness such as gender
and patient-reported symptoms and function (Webster, Nagelli,
Hewett, &Feller, 2018), some of which may be modied by the
therapist to assist the transition toward sport in their ACLR pa-
tients. Nevertheless, the inability of the current survey to more
accurately ascertain how therapists evaluated psychological read-
iness was a study limitation. Overall, most therapists in the current
study appeared to adopt a battery that included strength and hop
measures, with a review of lower limb and trunk mechanics during
functional tasks, often combined with a subjective review of psy-
chological readiness and another functional test (i.e. SEBT and/or
YBT), which is supported by current recommendations (van Melick
et al., 2016).
We do acknowledge a range of further study limitations, in
addition to those alluded to above. First, the nature of the survey
and how it was disseminated may have created potential for
response bias, with many of the following factors not accounted for
and potentially contributing to variation in treatment approaches.
The survey was made available exclusively to Physiotherapists and
AEPs, though the distribution of respondents across these disci-
plines was unknown. This survey failed to specically ask about
respondent clinical experience and/or clinical practice setting, nor
whether the respondent was a Physiotherapist or AEP. The latter
was not included as a specic question as both of these primary
allied health providers in Australia provide a similar service toACLR
patients both before and after surgery, as well as in that RTS deci-
sion making process. Furthermore, while this survey was made
available specically to Physiotherapists (via the APA) and AEPs (via
ESSA) the link was open to other respondents and did not require a
respondent-specic log in. While made available via APA/ESSA
Member portals and State/National News Bulletins, we acknowl-
edge that therapists from other disciplines could have been made
aware of the survey link and completed the survey. Alternatively,
therapists that completed the survey could have been dishonest
about their primary area of expertise and/or how many ACLR pa-
tients they see annually. A greater degree of variation in rehabili-
tation and RTS practices may have been found if the wider physical
therapy and sports training disciplines were included.
While n ¼223 completed the survey, we were unable to ascer-
tain a survey response rate given the nature of survey dissemina-
tion. While respondents were asked to answer the survey questions
based on their current practice with their ACLR patients, and it was
clearly stated that if therapists were not working with these pa-
tients, they should not complete the survey, we were unable to
J.R. Ebert et al. / Physical Therapy in Sport 35 (2019) 139e145 143
know exactly how many of the Physiotherapists and AEPs that were
made aware of the survey, were actually actively working with
ACLR patients. Therefore, calculating a response rate was made
impossible (i.e. what percentage of therapists actively working
with ACLR patients, actually completed the survey). Furthermore,
while Survey Monkey does not allow the survey to be completed on
multiple occasions from the same respondent's computer and
internet browser; while unlikely, we are unable to say whether
individual respondents completed the same survey multiple times
via accessing the same link from varied internet browsers. Some of
the aforementioned issues may have been addressed through the
survey requesting respondent identifying information to ensure
respondent profession. While there are also benets to anonymous
surveys (with respect to honest respondent information), the
anonymous nature of the survey was a requirement of not only
ethics approval, but a pre-requisite of both governing bodies
involved in disseminating the survey on the research team's behalf
in order to target the appropriate cohort (APA for Physiotherapists
and ESSA for AEPs).
The authors also assumed that the respondents that spanned all
Australian states provided a good representation of the Australian
therapy landscape. This survey was developed as a collaborative
project with input from different disciplines (academics, Physio-
therapists, AEPs and orthopaedic surgeons), though it was not
validated prior to dissemination. Finally, the survey aimed to obtain
an overview of the current beliefs and practices of Australian
therapists in rehabilitation and RTS, though it did not proceed to
seek specic information on the components of rehabilitation or
specic ways certain RTS considerations were evaluated (e.g.
whether psychological readiness was considered a factor that
inuenced RTS discharged was asked of respondents, though the
method of specically evaluating this was not explored). This is an
area for future research, and there was concern amongst the survey
development team that a survey overly burdensome would not be
so well responded to.
5. Conclusion
The results of this survey disseminated to Australian Physio-
therapists and AEPs working with ACLR patients revealed differ-
ences regarding views and practices surrounding rehabilitation and
RTS (timing and evaluation methods). The value of pre- and post-
operative rehabilitation is well acknowledged amongst therapists,
though the initiation of post-operative rehabilitation, and fre-
quency of supervised patient visitation through the early and later
stages of recovery, is varied. Variation also exists in the timing of
RTS discharge, as well as the tools employed to evaluate patients
prior to RTS.
Ethical statement
Ethics approval was obtained by the University of Western
Australia (RA/4/20/4328), and all participants provided content.
Declaration of interests
None (all authors).
Funding
This research did not receive any specic grant from funding
agencies in the public, commercial, or not-for-prot sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ptsp.2018.12.004.
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Article
Full-text available
Background Anterior cruciate ligament reconstruction (ACLR) may not restore lower limb biomechanics during single-limb landings. Objectives Our objective was to identify and evaluate differences in lower limb biomechanics during high-demand single-limb landings between the ACLR limb and the contralateral limb and healthy control participants. MethodsA systematic review of the literature was conducted using six electronic databases searched until April 2017 for published peer-reviewed studies that investigated lower limb biomechanics on the ACLR limb compared with either the contralateral limb or those of control participants. Meta-analysis with standardized mean differences (SMD) were performed for peak angles and moments (hip, knee and ankle joints) in the sagittal plane during single-limb landing tasks. ResultsA total of 35 studies met inclusion criteria. Four different single-leg landing tasks were identified: forward hop (n = 24 studies), landing from a height (n = 9 studies), vertical hop (n = 4 studies), and diagonal leap (n = 1 study). A reduced peak knee flexion angle was found in the ACLR limb compared with the contralateral limb during a forward hop landing task (SMD − 0.39; 95% confidence interval [CI] − 0.59 to − 0.18) and compared with a control group (SMD between − 1.01 and − 0.45) for all three reported single-leg landing tasks: forward hop, landing from a height, and diagonal leap. Similarly, a reduced peak knee internal extensor moment was found in the ACLR limb compared with the contralateral limb for all three reported landing tasks: forward hop, landing from a height, vertical hop (SMD between − 1.43 and − 0.53), and in two of three landing tasks when compared with a control group (SMD between − 1.2 and − 0.52). No significant differences in peak flexion (hip and ankle) angle or peak (hip and ankle) internal extensor moment were found in the ACLR limb compared with both the contralateral limb and a control group. Conclusions Participants performed single-limb landings on the ACLR limb with reductions in peak sagittal knee kinematics as well as peak joint moments compared with both the contralateral limb and a control group. Stiffer single-leg landings potentially expose the knee joint to higher forces, which may increase risk of injury. Clinical testing after ACLR surgery should explore movement quality as well as performance of functional tasks. Level of evidenceCase–control, IV
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Purpose: The purpose of the current prospective study was to assess the changes over time in patients tested at 6 months and 9 months after anterior cruciate ligament reconstruction (ACLR) with a return to sport (RTS) test battery. It was hypothesized that more patients passed RTS criteria at 9 months compared to 6 months. Methods: Sixty-two ACLR patients performed a test battery at an average of 6.5 ± 0.7 and 9.5 ± 0.9 months after ACLR. All patients underwent a standardized rehabilitation protocol. The test battery consisted of the following tests: a jump-landing task assessed with the Landing Error Scoring System (LESS), three single-leg hop tasks (single-leg hop test, triple-leg hop test, side hop test), isokinetic quadriceps and hamstring strength at 60, 180 and 300°/s and two questionnaires (IKDC and ACL-RSI). Cut off criteria were set as Limb Symmetry Index (LSI) > 90% (for isokinetic strength and for single-leg hop tasks), LESS < 5, IKDC score within 15th percentage of healthy subjects and ACL-RSI > 56 respectively. Results: At 6 months, two patients (3.2%) passed all criteria. At 9 months, seven patients (11.3%) passed all criteria. Patients improved in all RTS criteria over time except for the IKDC score. Twenty-nine patients (46.8%) did not pass the strength criterion at 60°/s at 9 months after ACLR. Conclusions: The percentages of patients passing all RTS criteria were low at both 6 and 9 months after ACLR. Quadriceps strength revealed persistent deficits and the lack of improvement in the IKDC score questionnaires shows insufficient self-reported knee function for RTS. Level of evidence: III.
Article
Background: Anterior cruciate ligament (ACL) injury has a significant psychological effect, and a negative psychological state is a commonly cited reason for a reduction or cessation of sports participation after ACL reconstruction (ACLR) surgery. Purpose: To identify factors that contribute to an athlete's psychological readiness to return to sport (RTS) after ACLR. Study design: Cross-sectional study; Level of evidence, 3. Methods: A cohort of 635 athletes (389 male, 246 female) who underwent ACLR and had been cleared to RTS completed the Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale at an average 12 months (range, 11-24 months) after surgery. Demographics (age, sex), sporting outcomes (preinjury frequency), surgical timing (injury to surgery interval), clinical factors (laxity), functional measures (single-limb hop symmetry), and symptoms of pain and function (International Knee Documentation Committee subjective) were also taken, and univariate and multiple regression models were used to determine the association between these and the psychological readiness of the athlete to RTS (ACL-RSI scores). Data for the entire cohort were initially analyzed; then, patients were grouped according to whether they had returned to competitive sport, and the analysis repeated for each group (return/nonreturn). Results: Univariate analysis for the entire group showed that all of the following had a positive effect on psychological readiness: male sex (β = 5.8; 95% CI, 2-10), younger age (β = -0.2; 95% CI, -0.4 to 0.01), a shorter interval between injury and surgery (β = -0.1; 95% CI, -0.1 to -0.02), a higher frequency of preinjury sport participation (β = 5.4; 95% CI, 2-9), greater limb symmetry (β = 0.5; 95% CI, 0.3-0.6), and higher subjective knee scores (β = 1.3; 95% CI, 1.1-1.4). In the multivariate model, subjective knee scores and age significantly accounted for 37% of the variance in psychological readiness ( r2 = 0.37, P < .0001). The only difference between the groups who had and had not returned to sport was that female sex was a significant contributor for the nonreturn group. Conclusion: Self-reported symptoms and function were most associated with psychological readiness to RTS after ACLR surgery. Male patients who participated frequently in sport before ACL injury had higher psychological readiness. Conversely, female patients had a more negative outlook and may therefore benefit more from interventions designed to facilitate a smooth transition back to sport.
Article
STUDY DESIGN Prospective cohort study. BACKGROUND While meeting objective criteria cutoffs are recommended prior to return-to-sport (RTS) following ACL reconstruction (ACLR), the number of young athletes meeting recommended cutoffs and their impact on longitudinal sports participation are unknown. OBJECTIVES To test the hypothesis that a higher proportion of young athletes who met recommended cutoffs would maintain the same level of sports participation over the year following RTS clearance compared to those who did not. METHODS At the time of RTS clearance, the International Knee Documentation Committee subjective form (IKDC), quadriceps and hamstring strength limb-symmetry indices (LSI), and single-leg hop test LSI were assessed. Proportions of participants meeting individual (IKDC ≥90; strength and hop test LSI ≥90%) and combined cutoffs were calculated. Proportions of participants who continued at the same level of sports participation over the year following RTS clearance (assessed using Tegner Activity scores) were compared between those who met and did not meet cutoffs. RESULTS Participants included 115 young athletes (88 females). The proportions meeting individual cutoffs ranged from 43.5% to 78.3%. The proportions meeting cutoffs for all hop tests, all strength tests, and all combined measures were 53.0%, 27.8%, and 13.9%, respectively. A higher proportion of participants who met cutoffs for both strength tests maintained the same level of sports participation over the year following RTS clearance than those who did not (81.3% vs. 60.2%; p=0.02). CONCLUSION The proportions of young athletes after ACLR recently cleared for RTS meeting combined criteria cutoffs were low. Those who met cutoffs for both strength tests maintained the same level of sports participation at higher proportions than those who did not. LEVEL OF EVIDENCE Level 2b – Prognosis. J Orthop Sports Phys Ther, Epub 7 Oct 2017. doi:10.2519/jospt.2017.7227
Article
Purpose: To investigate strength and functional symmetry during common tests in patients after anterior cruciate ligament reconstruction (ACLR), and its association with post-operative rehabilitation. Methods: At a median 11.0 months post-surgery (range 10-14), 111 ACLR patients were assessed. A rehabilitation grading tool was employed to evaluate the duration and supervision of rehabilitation, as well as whether structured jumping, landing and agility exercises were undertaken. Patients completed the Noyes Activity Score (NSARS), maximal isokinetic knee extensor and flexor strength assessment, and a 4-hop test battery. Limb Symmetry Indices (LSIs) were calculated, presented for the entire group and also stratified by activity level. ANOVA evaluated differences between the operated and unaffected limbs across all tests. Correlations were undertaken to assess the relationship between post-operative rehabilitation and objective test LSIs. Results: The unaffected limb was significantly better (p < 0.0001) than the operated limb for all tests. Only 52-61 patients (47-55%) demonstrated LSIs ≥ 90% for each of the hop tests. Only 34 (30.6%) and 61 (55.0%) patients were ≥ 90% LSI for peak quadriceps and hamstring strength, respectively. Specifically in patients actively participating in jumping, pivoting, cutting, twisting and/or turning sports, 21 patients (36.8%) still demonstrated an LSI < 90% for the single hop for distance, with 37 patients (65.0%) at < 90% for peak knee extension strength. Rehabilitation was significantly associated with the LSIs for all tests. Conclusion: Rehabilitation was significantly correlated with limb symmetry, and lower limb symmetry was below recommended criterion for many community-level ACLR patients, including those already engaging in riskier activities. It is clear that many patients are not undertaking the rehabilitation required to address post-operative strength and functional deficits, and are being cleared to return to sport (or are returning on their own accord) without appropriate evaluation and further guidance. Level of evidence: IV.
Article
Study Design Retrospective cohort. Background Star Excursion Balance Test (SEBT) performance differs by sport in healthy collegiate athletes and lower extremity injury rates also vary among sports, sex, and athletic exposure. The relationship between SEBT performance and injury risk has not been evaluated with consideration of these additional variables which may be necessary to fully describe the relationship between SEBT performance and injury risk. Objectives To assess the association between pre-season SEBT performance and non-contact injury occurrence to the knee or ankle in Division I collegiate athletes when controlling for sport, sex, and athletic exposure. Methods SEBT performance, starting status, and injury status were reviewed retrospectively for NCAA Division I collegiate athletes from a single institution. A total of 147 athletes were healthy at the time of pre-season SEBT testing and either remained healthy (N=118) or sustained a non-contact injury to the knee or ankle (N=29) during their sport's subsequent competitive season. Side-to-side asymmetries were calculated in each direction as the absolute difference in reach distance between limbs. SEBT reach distances and asymmetries were compared between groups using multivariable regression controlling for sport, sex, and athletic exposure (starter, non-starter). ROC curves were used to determine optimal sensitivity and specificity for significant models. Results When controlling for sport, sex, and athletic exposure, the SEBT ANT direction side-to-side asymmetry, expressed as an absolute or normalized to limb length, discriminated between injured and non-injured athletes (AUCs >0.82). Conclusion Assessing side-to-side reach asymmetry in the ANT direction of the SEBT may assist in identifying collegiate athletes who are at risk for sustaining non-contact injuries to the knee or ankle. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther, Epub 29 Mar 2017. doi:10.2519/jospt.2017.6974.
Article
STUDY DESIGN: Clinical measurement, cross-sectional. BACKGROUND: Quadriceps defcits are common in individuals with knee joint impairments and impact functional and quality-of-life outcomes. Quadriceps strength symmetry inffuences clinical decisions after knee injury. Isometric electromechanical dynamometry (ISO-ED) is the gold standard for measuring symmetry, but is not available in all clinical settings. OBJECTIVES: To compare concurrent validity of handheld dynamometry and 1-repetition-maximum leg press, knee extension from 90° to 0°, and knee extension from 90° to 45° to that of ISO-ED in identifying meaningful quadriceps strength defcits. METHODS: Fifty-six participants with knee joint impairments completed ISO-ED and 4 alternative measures of quadriceps strength symmetry in a single session. Absolute agreement of alternative measures with ISO-ED was calculated with intraclass correlation coefcients (ICCs). Clinical agreement values at thresholds of 80% and 90% symmetry were compared between the alternatives and ISO-ED. RESULTS: Knee extension from 90° to 45° (ICC = 0.67) and handheld dynamometry (ICC = 0.70) had the greatest ICCs. Clinical agreement was also best for these measures for 80% symmetry (ff = 0.56 and 0.55, respectively) and 90% symmetry (ff = 0.19 and 0.33, respectively). CONCLUSION: Handheld dynamometry and 1-repetition-maximum testing of knee extension from 90° to 45° are fair alternatives, although symmetry is typically overestimated. Receiver operating characteristic analysis identifed alternative measure thresholds that correlated with the 80% and 90% symmetry thresholds on the ISO-ED. Clinicians should use more stringent symmetry values for these alternative tests to increase the probability that individuals have a minimum ISO-ED symmetry of 80% or 90%.