The development of long-term osteoarthritis following anterior cruciate ligament injury: reconstruction vs no reconstruction.

PURPOSE: The high incidence of osteoarthritis (OA) in relatively young sportspeople following anterior cruciate ligament (ACL) reconstruction is concerning. Surgery is considered to reduce the development of OA compared to conservative management. This long-term study aimed to compare the incidence and severity of tibiofemoral OA (TFOA) and patellofemoral OA (PFOA) between reconstructed and non-reconstructed treatment groups and to determine which factors influence the development of OA. MATERIALS AND METHODS: Fifty-six ACL-reconstructed and 45 conservatively treated patients from a cohort of 330 were followed for 11 years (mean) post-injury. Twenty-nine patients had received a bone-patellar tendon-bone (B-PT-B) graft, and 27 had received a hamstring (semitendinosus/gracilis) tendon (HT) graft. Assessment included objective and subjective stability, quadriceps and hamstring strength and radiology. Chi-square analyses compared OA between reconstructed and non-reconstructed groups and between B-PT-B, HT and non-surgical groups. Further analysis assessed the relationship between OA and age, time post-injury, meniscal injury/meniscectomy, quadriceps strength, hamstring strength, objective and subjective stability and sporting activity. RESULTS: Forty-eight per cent reconstructed  and 53% non-reconstructed patients developed TFOA (p = 0.690). Thirty-six per cent reconstructed and 38% non-reconstructed patients developed PFOA (p = 0.831) with moderate PFOA occurring only in the non-reconstructed group. Close to significant differences (p = 0.075) were found comparing the severity of TFOA between groups with a higher incidence of moderate/severe OA in the non-reconstructed and B-PT-B groups. TFOA differed significantly between the B-PT-B and HT groups. The development of OA was related to age, time post-injury, meniscal injury/meniscectomy, quadriceps strength and subjective stability. CONCLUSIONS: There were no significant differences in OA incidence between reconstructed and non-reconstructed groups but fewer patients developed TFOA following HT grafting compared to B-PT-B grafting and to non-surgical treatment. Quadriceps weakness and meniscal injuries/meniscectomy, both potentially modifiable, were strongly associated with the development of TF and PFOA.

Long-term Return to Sports After Anterior Cruciate Ligament Injury: Reconstruction vs No Reconstruction-A Comparison of 2 Case Series.

BACKGROUND: Reconstruction is considered to provide the best opportunity for return to sports (RTS) after anterior cruciate ligament (ACL) rupture. However, recent studies report that <50% of athletes return to preinjury sporting levels and that RTS rates at 1 year after injury are the same for athletes undergoing reconstruction and nonoperative management. Long-term studies are essential to confirm these findings and guide decisions regarding surgery. PURPOSE: First, to compare long-term sports participation after ACL reconstruction and nonreconstruction and, second, to relate RTS level to strength and stability. STUDY DESIGN: Cohort study; Level of evidence, 3. METHOD: Patients with ACL deficiency (n = 101) who were referred for physical therapy at the time of diagnosis were followed long term: 56 were treated surgically 2.5 years (interquartile range [IQR], 1-4) after injury and 45 were treated nonoperatively. At long-term follow-up, the reconstructed group was at 9 years (IQR, 7-11) after injury and aged 33.3 ± 6.2 years (mean ± SD, 70% male; 61% meniscal injury), and the nonreconstructed group was at 11 years (IQR, 7-14) after injury and aged 38.7 ± 8.3 years (67% male; 58% meniscal injury). Measures of objective stability, subjective stability, and quadriceps/hamstring strength were compared between groups using independent-samples t tests. Current RTS level, scored on a 6-point scale, was compared between groups using chi-square tests. Spearman rho correlated RTS with outcome measures. RESULTS: Of the total group of patients, 96% with reconstruction and 93% without continued to play sports. In the reconstructed and nonreconstructed groups, 4% and 7% did not RTS, and 8% and 17% returned to safe sports, respectively: 13% and 12% to running, 20% and 26% to sports involving limited twisting, 12% and 24% to recreational pivoting sports, and 43% and 14% to competitive pivoting sports. The only significant difference was in return to competitive pivoting sports (P = .003). Five patients with reconstruction ruptured the contralateral ACL, and 1 ruptured his graft. Most patients treated nonoperatively modified their sports participation. Their RTS levels correlated significantly with quadriceps strength (r = 0.65; P < .001), hamstring strength (r = 0.721; P < .001), and subjective stability (r = 0.405; P = .01). CONCLUSION: Surgically treated patients returned to competitive pivoting sports at 3 times the rate of those managed nonoperatively, confirming that reconstruction provides the best opportunity for continued participation in competitive pivoting sports. Regardless of grouping, RTS correlated with modifiable factors, including strength and stability. Higher rates of subsequent injuries observed after reconstruction may result from increased participation in competitive pivoting sports.

Generalized joint hypermobility in siblings with anterior cruciate ligament injuries and matched unrelated healthy siblings.

BACKGROUND AND PURPOSE: Anterior cruciate ligament (ACL) ruptures are common knee injuries, and siblings of individuals with an ACL injury may be at higher risk of ACL injury. Generalized hypermobility may be a familial factor predisposing siblings to ACL injury and may also relate to faulty lower limb alignment. There is a need to determine whether the interaction between hypermobility, family history, and faulty alignment makes siblings with hypermobility at higher risk for ACL injury so that appropriate preventative measures can be taken. This study therefore aimed to (a) compare the prevalence of generalized hypermobility and faulty limb alignment in siblings with and without injury and (b) assess the relationship between generalized hypermobility and lower limb alignment. METHODS: In this case-controlled study, 24 siblings with ACL injuries from 10 families were matched with 24 healthy uninjured siblings from 10 unrelated families. Generalized hypermobility was assessed using Beighton's criteria. Chi-square analyses compared generalized hypermobility and lower limb alignment between siblings and sibling pairs with and without injuries. Spearman's rho was used to assess correlations between generalized hypermobility and lower limb alignment. RESULTS: There were significant differences between the number of injured and uninjured siblings demonstrating generalized hypermobility when tallied individually (p = .003) and in same-family sibling pairs (p = .019). Significant (or close) differences were found between siblings for knee hyperextension (p < .001), knee valgus (p = .01), and foot pronation (p = .002) and for sibling pairs sharing knee hyperextension (p < .001), knee valgus (p = .06), and foot pronation (p = .06). Generalized hypermobility correlated with knee hyperextension (rs = .722; p < .001), knee valgus (rs = .385; p = .007), and foot pronation (rs = .328; p = .023). CONCLUSIONS: Generalized hypermobility and faulty limb alignment occur significantly more frequently in injured than uninjured families. Screening for both features would assist in identifying at-risk siblings. Prevention programmes reduce ACL injuries by 50-70% and should target hypermobile siblings of the ACL injured.

Nearly 90% participation in sports activity 12 years after non-surgical management for anterior cruciate ligament injury relates to physical outcome measures.

PURPOSE: Traditionally reconstructive surgery is recommended for patients planning to return to sport (RTS), especially to pivoting sports after anterior cruciate (ACL) rupture. Recent trends focus on delaying or avoiding surgery as some studies have found similar rates of RTS following both surgical and conservative management. This study aimed to establish long-term RTS levels in ACL-ruptured individuals treated conservatively, and to investigate the relationship between outcome measures and RTS, in particular, pivoting sports. METHOD: Fifty-five patients from a cohort of 132 ACL-deficient patients were followed-up for  12 (IQR 8,19) years post injury. Mean-aged 42 years, 22 patients were females and 33 males, 35 had meniscal injuries. Patients were treated with physiotherapy focussing on strength and dynamic stability training and not reconstructive surgery. Return to sport was measured on a 6-point scale. Outcome measures included: objective stability, subjective stability, quadriceps and hamstring strength. Spearman's rho and Chi-square tests were used to assess the relationship between RTS and outcome measures. RESULTS: Eighty-nine percent of ACL-deficient patients were currently participating in sport despite a 38% increase in anterior translation (p < 0.001) and a 7.5% loss of quadriceps strength (p = 0.004) compared to the contralateral side. Six patients (11%) did not RTS, ten (18%) returned to safe sports, five (9%) returned to running and 16 (29%) to non-strenuous sports involving limited twisting. Eighteen patients (33%) returned to pivoting sports, 12(22%) at recreational level and six (11%) at competitive level. The level of RTS was related to subjective stability (p = 0.002), and to quadriceps and hamstring strength of the injured leg (p < 0.001). Patients able to return to pivoting sports differed significantly from those not doing so in outcome measures including objective (p = 0.022) and subjective stability (p = 0.035), and quadriceps strength (p = 0.044). CONCLUSIONS: Eighty-nine percent of ACL-ruptured individuals treated conservatively lead an active sporting life. One-third returned to pivoting sports.  Overall RTS was related to subjective and objective stability and quadriceps and to a lesser extent hamstring strength. This finding reinforced the importance of dynamic stability training as an initial treatment option in most cases. LEVEL OF EVIDENCE: III.

Three-Year Outcome After a 1-Month Physiotherapy Program of Local and Individualized Global Treatment for Patellofemoral Pain Followed by Self-Management.

OBJECTIVE: The main aim of this study was to assess whether improvements after a 1-month patellofemoral pain (PFP) program addressing local and global deficits were maintained for 3 years. DESIGN: This prospective cohort study comprised 4 treatment phases including a randomized trial during week 1. SETTING: The study was conducted in a private physiotherapy practice. PATIENTS: Thirty-seven patients (55 knees) from an original cohort of 41 patients (60 knees) with PFP were followed for 3 years after referral by doctors to participate in this study. INTERVENTIONS: Patients received 4 treatments: local treatment focusing on quadriceps strengthening, quadriceps stretching, and taping for fortnight 1, supplemented with individualized global treatment focusing on lower limb posture and movement patterns for fortnight 2, followed by ongoing self-management. MAIN OUTCOME MEASURES: Seven outcome measures, assessed at 4 time points, were quadriceps strength, quadriceps length, eccentric knee control, and 4 pain measures. Long-term measures included return to sporting activity, pain recurrence, exercise compliance, and Kujala score. RESULTS: Improvements after fortnight 1 (P < 0.001) and fortnight 2 (P < 0.05) were maintained over 3 years for 6 of 7 measures. On testing, 73% were pain free and the remaining 27% had less pain than pretreatment. Kujala scores improved 27%. Eighty-two percent resumed any sport stopped and 54% of patients started new sports/activities. Patellofemoral pain recurred in 7% and 89% of patients was still exercising 3 years posttreatment. CONCLUSIONS: Significant improvements after physiotherapy, incorporating local and individually targeted treatment, were maintained for 3 years in a compliant cohort.

Individualized physiotherapy in the treatment of patellofemoral pain.

BACKGROUND AND PURPOSE: Patellofemoral pain (PFP) is associated with a wide range of local and global physical factors possibly contributing to pain and thus requires detailed assessment and individualized treatment. Yet, no cohort study was found that assessed the value of individualized physiotherapy, probably because this approach lends itself to clinical practice but not to scientific research. Most studies focus on a 'knee' or 'hip' treatment approach irrespective of individual global differences in lower limb alignment, movement patterns and muscle tightness. Therefore, this study aimed to determine the effectiveness of supplementing local treatment of PFP with individualized treatment targeting global contributing factors. Secondarily it aimed to subgroup the patients according to variations in lower limb alignment/laxity, movement patterns, biarticular muscle tightness and joint degeneration. METHOD: Forty-one patients (60 knees) with PFP who had followed a programme of local quadriceps strengthening, quadriceps stretching and taping for one fortnight were prescribed an individualized programme based on assessment. This global assessment included lower limb postural alignment, movement patterns, muscle tightness and range of motion. Another fortnight's treatment was prescribed accordingly and included specific, individualized postural and movement retraining, stretching and functional weight-bearing, strengthening exercises. Seven outcome measures, namely four pain measures, isokinetic quadriceps strength, quadriceps length and eccentric knee control, assessed improvement. RESULTS: All outcome measures showed further significant improvement following individualized treatment (p < 0.03). Patients fell into four broad physical subgroups: hypermobility (often with malalignment), hypomobility (with three of four tight muscle groups), faulty movement patterns (mostly dynamic knee valgus) and patellofemoral osteoarthritis. CONCLUSIONS: Individualized treatment supplementing local standard physiotherapy for PFP leads to further significant improvement over 2 weeks. This study highlights the importance of assessing patients globally in order to optimize treatment and ongoing improvement. Recognition of different subgroups may guide treatment that should include both local and deficit-targeted global treatment.

The effect of anterior cruciate ligament rupture on the timing and amplitude of gastrocnemius muscle activation: a study of alterations in EMG measures and their relationship to knee joint stability.

Changes in hamstring and quadriceps activity are well known in individuals with anterior cruciate ligament deficiency (ACLD) to potentially compensate for knee joint instability. However, few studies have explored gastrocnemius activity or its relationship to knee stability. The purpose of this study was therefore to examine the activation characteristics of medial gastrocnemius (MG) in ACLD subjects and relate any changes to knee joint laxity. Two subject cohorts were assessed: those with unilateral ACLD (n=15) and uninjured control subjects (n=11). Surface EMG of the left and right MG were recorded during a controlled single leg hop on each limb. Onset and offset of MG activation relative to take-off, during flight and landing were calculated as well as muscle activity (RMS). Passive antero-posterior knee laxity was measured with a KT1000 arthrometer during a maximal manual displacement test. Medial gastrocnemius activity on the injured side of ACLD participants demonstrated significantly prolonged activation in preparation to hop, minimal muscle inactivity prior to take-off, and increased duration of overall muscle activity when compared to the uninjured side and control subjects (p<0.05). Significant positive correlations were found between passive knee joint laxity and prolonged activation prior to knee bend. RMS of the muscle signal was not significantly different between limbs. Overall, MG on the ACLD side demonstrated longer activation, with minimal rest during the hop test, which may be an attempt to maintain knee stability. Furthermore, the strong relationship between knee laxity and prolonged muscle activation suggests that individuals with a loss of knee stability are more reliant on active control of the gastrocnemius muscle.

The effect of taping, quadriceps strengthening and stretching prescribed separately or combined on patellofemoral pain.

BACKGROUND AND PURPOSE: Quadriceps strengthening, quadriceps stretching and patellar taping are commonly prescribed together for patellofemoral pain patients. This study aimed to examine the effectiveness of each of these techniques in isolation for one week and in combination for one week. METHODS: A prospective double-blind randomized control study was designed involving 41 subjects with 60 knees diagnosed with patellofemoral pain. The knees were randomized in onto one of four groups (n = 15): infrapatellar taping, quadriceps strengthening, quadriceps stretching and control. The taping was worn continually for the week; the strengthening group followed a programme of non-weight-bearing terminal range quadriceps exercises, the stretching group performed rectus femoris stretches. The control group did not receive treatment. All subjects received advice. Seven pre- and post-treatment measures included isokinetic quadriceps strength, quadriceps length, pain measured during four activities and maximum eccentric, posturally controlled, pain-free knee flexion angle during a step-down. Results showed significant changes over time (p < 0.01) in two out of seven measures for the taping group, in five out of seven for the strengthening group and five out of seven for the stretching group and none in the control group. When the three modalities were combined for one week, (n = 60) all seven measures improved significantly (p < 0.01). CONCLUSION: In isolation, quadriceps stretching and quadriceps strengthening resulted in more improvements than taping. Combining these treatments is recommended as the initial approach to treating patellofemoral pain but further individualized more functional, global treatment is essential.

Factors involved in the development of osteoarthritis after anterior cruciate ligament surgery.

BACKGROUND: The incidence of osteoarthritis after anterior cruciate ligament reconstruction is disturbingly high, with reports of nearly 50% of patients developing mild to moderate osteoarthritis 6 years after surgery. Few studies have assessed the factors involved in the development of osteoarthritis. HYPOTHESIS: The following 10 factors will be found to be predictive of osteoarthritis: meniscectomy, chondral damage, patellar tendon grafting, age at surgery, time delay between injury and surgery, type and intensity of postsurgery sport, quadriceps strength, hamstring strength, quadriceps-to-hamstring strength ratio, and residual joint laxity. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 1. METHODS: Fifty-six subjects with anterior cruciate ligament reconstruction were followed for 6 years after surgery. Assessment included KT-1000 arthrometer testing, isokinetic strength testing, a return-to-sport questionnaire, and a radiograph assessment. A discriminant analysis was performed to assess which of the 10 factors could discriminate between those patients who developed tibiofemoral and patellofemoral osteoarthritis and those who did not. RESULTS: Five factors were found to be predictive of tibiofemoral osteoarthritis. Meniscectomy (r = .72) and chondral damage (r = .41) were the strongest discriminators, followed by patellar tendon grafting (r = .37) (chi(2) [7, n = 56] = 25.48; P = .001). Weak quadriceps (r = .39) and low quadriceps-to-hamstring strength ratios (r = .6) were very close discriminators (chi(2) [8, n = 42] = 15.02; P = .059). For patellofemoral osteoarthritis, meniscectomy (r = .45), chondral damage (r = .75), and age at surgery (r = .65) were predictors or close predictors (chi(2) [7, n = 54] = 13.30; P = .065). CONCLUSION: As not all 10 factors studied were predictive of osteoarthritis, the hypothesis was only partially proven. Preventing further meniscal and chondral damage in patients with anterior cruciate ligament deficiency is critical. Grafting using the hamstring tendons and restoration of quadriceps-to-hamstring strength balance are associated with less osteoarthritis.

A 6-year follow-up of the effect of graft site on strength, stability, range of motion, function, and joint degeneration after anterior cruciate ligament reconstruction: patellar tendon versus semitendinosus and Gracilis tendon graft.

BACKGROUND: The choice of graft material for anterior cruciate ligament reconstruction remains controversial. Despite the need for well-controlled, long-term outcome studies comparing patellar tendon with hamstring grafting, few studies have followed results for more than 5 years. HYPOTHESIS: Graft source will not affect outcome 6 years after reconstruction. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Sixty-two patients with anterior cruciate ligament reconstruction and 18 uninjured control subjects were studied over 6 years. Thirty-one patients received patellar tendon grafts, and 31 received hamstring tendon grafts. Assessment included knee joint stability, range of motion, muscle strength, subjective function, objective function (running, sidestepping, carioca, and hop tests), and joint degeneration. RESULTS: Clinical stability was restored to all patients other than to the 2 hamstring graft recipients who suffered reinjuries. The KT-1000 arthrometer side-to-side differences were similar in the patellar tendon (1.9 mm) and hamstring tendon (2.0 mm) groups but were significantly greater than that of uninjured control subjects (P < .001). There were no significant strength differences between surgical and control groups, although a 6% quadriceps deficit existed after patellar tendon grafting. In the more demanding functional tests (hop and triple-hop indices and carioca), the hamstring graft recipients performed similarly to the control group, whereas a significant difference (P < .05) existed between the patellar tendon graft and the control group. The incidence of early tibiofemoral osteoarthritis was significantly greater after reconstruction using patellar tendon (62%) than after hamstring tendon grafting (33%; P = .002). CONCLUSION: Six-year outcomes were very satisfactory irrespective of graft source. However, reconstruction using the hamstring tendons resulted in improved functional performance and a lower incidence of osteoarthritis.