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