Raising the bar: outcomes in athletes after ACL injury and reconstruction
Date
2016
Authors
Journal Title
Journal ISSN
Volume Title
Publisher
University of Delaware
Abstract
Anterior cruciate ligament (ACL) injury is a transformative and demoralizing
knee injury commonly affecting athletes who participate in activities where jumping,
cutting, and pivoting maneuvers are frequently used. Emerging outcomes research
suggests recovery after ACL injury is more vexed than previously thought. Many
athletes continue to experience less than normal knee function despite modern
advances in arthroscopic surgical technology, various graft options, and the
development of rehabilitation standards. Merely reconstructing the ligamentous tear
does not guarantee return to previous level of function, return to previous activity or
activity level, and does not prevent post-traumatic osteoarthritis development. ☐ While factors such as age, sex, body mass index (BMI), graft type,
concomitant injury, and surgical variables are associated with altered outcomes; these
factors are non-modifiable to rehabilitation professionals. Establishing modifiable
factors associated with outcomes after ACL injury and ACLR can lead to the potential
to impact standards of care and rehabilitation protocols to impede poor outcomes in
the future. Pre-operative rehabilitation has been shown to lead to improved outcomes
following ACLR. The addition of pre-operative milestones prior to undergoing ACLR
have been used to reduce negative outcomes, such as arthrofibrosis and quadriceps
strength weakness. ☐ The purpose of this work is to examine the effects of pre-operative
rehabilitation on improving outcomes 2 years after ACLR, examining pre- and early
post-operative modifiable factors that are related to 2 year outcomes, and explore
second injury rates and predictors in a cohort that underwent extended pre-operative
rehabilitation. ☐ Athletes with ACL injury who underwent ACLR served as subjects for this work. Athletes completed demographic, clinical, functional, and patient-reported
outcome measures before and after an extended program of pre-operative
rehabilitation. Subjects returned at 6 months and 24 months after reconstruction for
follow-up testing. Second injury rates and successful or unsuccessful outcomes
assessment was completed at 2 year follow-up. ☐ The addition of extended pre-operative training was associated with higher
functional outcome scores at 2 years after reconstruction. Besides improving
outcomes, waiting until completion of the extended pre-operative rehabilitation to
perform a screening battery resulted in a more robust prediction of function 2 years
after ACLR. Clinical and functional measures that are modifiable to rehabilitation
specialists successfully predicted 2 year function as well as successful or unsuccessful
outcome following ACLR. The benefits of additional rehabilitation and higher
standards are evident throughout this work. Raising the bar of pre-operative strength,
functional performance, and patient-reported outcome scores was associated with
higher functional scores 2 years after ACLR. This highlights the importance of
achieving higher clinical and functional standards before undergoing ACLR. In
addition, the need to achieve higher standards of function early after ACLR features
the importance of progressive post-operative protocols and utilizing objective
measures to identify those at increased risk of poorer outcomes or second ACL injury.
No matter the time-point, success was associated with higher clinical and functional
outcomes further perpetuating the importance of rehabilitation in improving outcomes.