Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Orthopaedic Journal of Sports Medicine, Jan 2014

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Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Downloaded from ojs.sagepub.com by guest on May Functional Performance Testing After Anterior Cruciate Ligament Reconstruction A Systematic Review 0 Geoffrey D. Abrams 0 Joshua D. Harris 0 Anil K. Gupta 0 Frank M. McCormick 0 Charles A. Bush-Joseph 0 Nikhil N. Verma 0 Brian J. Cole 0 Bernard R. Bach Jr 0 0 Investigation performed at Rush University Medical Center , Chicago, Illinois , USA Background: When to allow an athlete to return to unrestricted sporting activity after anterior cruciate ligament (ACL) reconstruction remains controversial. Purpose: To report the results of functional performance testing reported in the literature for individuals at differing time points following ACL reconstruction and to examine differences between graft types. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic review of Medline, Scopus, and Cochrane Central Register of Controlled Trials was performed using PRISMA guidelines. Inclusion criteria were English-language studies that examined any functional rehabilitation test from 6 months to 2 years following ACL reconstruction. All patient-, limb-, and knee-specific demographics were extracted from included investigations. All functional rehabilitation tests were analyzed and compared when applicable. Results: The search term returned a total of 890 potential studies, with 88 meeting inclusion and exclusion criteria. A total of 4927 patients were included, of which 66% were male. The mean patient age was 26.5 ± 3.4 years. The predominant graft choices for reconstruction were bone-patellar tendon-bone (BPTB) autograft (59.8%) and hamstring autograft (37.9%). The most commonly reported functional tests were the hop tests. The results of these functional tests, as reported in the Limb Symmetry Index (LSI), improved with increasing time, with nearly all results greater than 90% at 1 year following primary ACL reconstruction. At 6 months postoperatively, a number of isokinetic strength measurements failed to reach 80% LSI, most commonly isokinetic knee extension testing in both BPTB and hamstring autograft groups. The knee flexion strength deficit was significantly less in the BPTB autograft group as compared with those having hamstring autograft at 1 year postoperatively, while no significant differences were found in isokinetic extension strength between the 2 groups. Conclusion: Hop testing was the most commonly reported functional test following ACL reconstruction. Increases in performance on functional tests were predictably seen as time increased following surgery. Those with hamstring autografts may experience increased strength deficits with knee flexion versus those having BPTB autograft. These data provide information that may assist providers in determining timing of return to unrestricted sporting activity. ACL; anterior; cruciate; ligament; functional test; hop; isokinetic - Anterior cruciate ligament (ACL) injuries are common in the young and athletically active population, with a reported incidence of 0.7 to 2.5 ACL tears per 1000 athleticexposures.78 It has been estimated that between 100,000 and 200,000 reconstructions are performed in the United States each year.13,22 Reconstruction of the ACL using either bone–patellar tendon–bone (BPTB) autograft,69 hamstring autograft,97 or allograft tissue25 has become standard for treatment in patients who have functional knee instability and a desire to return to cutting and pivoting sports. Clinical follow-up has shown a high rate of return to previous level of activity using modern arthroscopically assisted reconstruction techniques.24,58,64,96 While the need for ACL reconstruction in athletically active individuals who desire a return to cutting and pivoting sports is generally accepted, there is a lack of consensus as to when an athlete may return to sport. In their review of 264 investigations, Barber-Westin and Noyes9 reported that criterion for return to play was not reported in 40% of studies, with an additional 32% of investigations using only postoperative time. Only 13% of the studies utilized objective criteria for determining when an athlete may return to sport. Deficits in neuromuscular control of the lower extremity are known to be a risk factor for secondary (retear) ACL injury and are therefore often used in assessing return-toplay readiness.75,100 Quadriceps strength, in particular, has been associated with physical functioning of the leg following ACL reconstruction.16,57 Additionally, some authors have evaluated the presence of neuromuscular impairment following ACL reconstruction and its association with secondary reinjury.75 Hip and knee positions predicted a second injury,75 emphasizing the importance of addressing these parameters during rehabilitation. To assist with returning a patient to sports, many groups have developed rehabilitation protocols, each with their own methods and return-to-play criteria.23,31,104 Areas of particular interest in determining ret (...truncated)


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Geoffrey D. Abrams, Joshua D. Harris, Anil K. Gupta, Frank M. McCormick, Charles A. Bush-Joseph, Nikhil N. Verma, Brian J. Cole, Bernard R. Bach Jr. Functional Performance Testing After Anterior Cruciate Ligament Reconstruction: A Systematic Review, Orthopaedic Journal of Sports Medicine, 2014, 2/1, DOI: 10.1177/2325967113518305