Symmetric or Sufficient for Return-to-Sport after ACL Injury? Science Meets Practice Session APTA Combined Sections Meeting 2018

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1 Symmetric or Sufficient for Return-to-Sport after ACL Injury? Science Meets Practice Session APTA Combined Sections Meeting 2018 Matthew Ithurburn, PT, PhD, DPT, OCS University of Alabama at Birmingham, Department of Physical Therapy Elizabeth Wellsandt, PT, PhD, DPT, OCS University of Nebraska, Division of Physical Therapy INTRODUCTION: ACL Reconstruction after ACL Injury Standard of care for ACL injuries in the United States Generally expected to: Restore joint stability Allow for return to preinjury activity/sport Poor RTS Outcomes after ACLR: Meta-analysis findings: When examining return to any level of sport over any period of time: 82% return When examining return to preinjury level of sport participation: only 63% return When examining return to competitive sports: Associated Sequelae: only 44% return Decreased Patient-Reported Knee Function Approximately one-third of individuals report an outcome of less than acceptable 2 years after ACLR 30% of individuals demonstrate KOOS-QOL scores <44/100 at 2 years Increased Risk of 2 nd ACL Injury High school age athletes: ~30% sustained 2 nd ACL injury within 2 years of RTS Recent meta-analysis data: 23% of athletes <25 years old sustained 2 nd ACL injury after RTS

2 What Typically Guides RTS Decisions? Post-operative timeline Medical team/surgeon opinion Objective measures of function/performance Of objective measures, most used: Strength Performance measures Often evaluated using symmetry measures: Debate Regarding Symmetry Measures after ACLR: Appropriate comparison for involved limb? Uninvolved limb de-conditioning? Bilateral injury effects? Purpose: To examine the evidence in support of evaluating symmetry measures (strength, performance, movement) vs. evaluating absolute performance measures (sufficiency) after ACLR Make clinical recommendations for practical use of symmetry and sufficiency measures in RTS decision-making after ACLR SYMMETRIC: Symmetry and Additional Knee Injury Grindem 2016, Br J Sports Med RTS test battery completed at 6 and 12 months post-aclr including: -Isokinetic quadriceps strength -SL hop tests -Self-reported function Tracked additional knee injuries over 24 months Lower quadriceps strength symmetry in those with reinjury (75.0% vs. 84.4%) When grouped by quadriceps LSI> or < 90%: Quadriceps LSI >90%: 12.5% sustained reinjury Quadriceps LSI <90%: 33.3% sustained reinjury Kyritsis 2016, Br J Sports Med

3 158 male professional athletes tested prior to RTS Isokinetic strength, hop and agility tests Tracked over time for occurrence of graft rupture Discharge criteria: Isokinetic quadriceps symmetry: >90% LSI Single hop, triple hop, crossover hop: >90% LSI Running t test: <11 seconds Completed on-field sport-specific rehab Met all discharge criteria: 10.3% sustained graft rupture Did not meet discharge criteria: 33.3% sustained graft rupture Paterno 2010, Am J Sports Med Drop landing mechanics tested at time of RTS in 56 young athletes 2 nd injury surveillance over 1 year post-rts Side-to-side asymmetries in sagittal plane knee moment Approximately 3 times higher odds of 2 nd ACL injury (OR=3.3) Symmetry and Return-to-Sport Success Toole 2017, J Orthop Sports Phys Ther 115 young athletes previously cleared to RTS How many met recommended RTS criterion cutoffs? Strength LSI, hop test LSI, IKDC scores Association between meeting cutoffs and continuing in sport participation over 1 year post-rts Only 28% met both quadriceps and hamstring LSI >90% Those that met both quadriceps and hamstring LSI >90%: Continued in sports participation over the year post-rts at higher proportions (81%) than those that did not meet both cutoffs (60%) Symmetry and Knee Function Schmitt 2012, JOSPT 55 young athletes previously cleared to RTS after ACLR and 35 healthy controls

4 Quadriceps strength tested at RTS Symmetric (HQ; Quad LSI 90%), Asymmetric (LQ; Quad LSI<90%) Compared IKDC scores and hop test performance Asymmetric quad strength group Lower IKDC scores at time of RTS Asymmetric quad strength group Worse hop test performance at time of RTS Ithurburn 2018, Knee Surg Sports Traumatol Arthrosc 76 young athletes tested at time of RTS clearance and 1 year later Quadriceps strength symmetry at RTS Symmetric (HQ; Quad LSI 90%) Asymmetric (LQ; Quad LSI<90%) KOOS and IKDC at 1 year Asymmetric quad strength group at RTS Lower KOOS-Sport and IKDC scores at 1 year Asymmetric quad strength group at RTS Lower proportions of functional recovery at 1 year Logerstedt 2012, Am J Sports Med 85 patients after ACLR were tested at 6 months and 1 year post-surgery 4 single-leg hop tests at 6 months (single, triple, crossover, 6m-timed) IKDC at 1 year IKDC scores categorized as within/outside normal range of age- and sex-norm values Higher SL hop test symmetry at 6 months = increased odds of normal IKDC scores at 1 year SUFFICIENT: Review of Meta-Analyses: When examining return to competitive sports: only 44% return (Ardern 2011, Br J Sports Med) Athletes <25 years old: 23% sustain 2 nd ACL injury after RTS (Wiggins, 2016, Am J Sports Med) Ipsilateral reinjury rate: 10% Contralateral reinjury rate: 12% Limb Symmetry Indexes (LSI s): Reasons for concern

5 Uninvolved limb de-conditioning Bilateral injury effects Is the function of the uninvolved limb adequate for comparison? Uninvolved limb de-conditioning Appell 1993, Sports Med Muscle atrophy Immobilization: lose 3-6% strength/day Thom 2001, Acta Physiol Scand Up to 40% decrease of initial 1 RM strength in 10 days Bilateral injury effects Neuromuscular alterations Lower neural excitability in BOTH limbs after ACL reconstruction compared to healthy control subjects Lepley 2015, Scand J Med Sci Sports Spinal-reflexive excitability and corticospinal excitability lower in both limbs compared to controls at 2 weeks post-aclr Pietrosimone 2015, J Athl Train 4 years post-op ACLR Hoffmann reflex higher bilaterally compared to controls (p=0.03) Injured: 0.27 ± 0.12; Uninjured: 0.28 ± 0.16; Control: 0.20 ± 0.13 Active motor threshold (AMT) higher in injured limb vs. controls No difference in uninjured limb Lower quadriceps muscle activation in BOTH limbs after ACL injury Lynch 2013, J Orthop Sports Phys Ther 49% with lower quad activation 1 months after ACL injury Urbach 1999, Med Sci Sports Exerc 4 months post-injury (N=22 ACL, 21 healthy, all men) Quadriceps activation lower bilaterally compared to controls (p= ) Injured: 83.9 ± 2.3%; Uninjured: 84.7 ± 2.2% Controls: 95% CI: % Pietrosimone 2015, J Athl Train 4 years post-op ACL reconstruction

6 Quadriceps activation lower bilaterally compared to controls (p=0.002) Injured: 88 ± 12%; Uninjured: 88 ± 12%; Control: 96 ± 4% Hart 2011, Knee Surg Sports Traumatol Arthrosc 4 years post-op ACL revision 76% with activation failure (<95%) in both reconstructed and contralateral limb Injured: 83.9 ± 12.0%; Uninjured: 85.5 ± 9.5% Bilateral injury effects Quadriceps Strength Urbach 1999, Med Sci Sports Exerc 4 months post-injury (N=22 ACL, 21 healthy, all men) Urbach 1999 (Med Sci Sports Exerc) Quadriceps strength (MVIC) lower bilaterally compared to controls Injured: 153 ± 9.6 Nm (p < 0.001) Uninjured: 189 ± 12.4 Nm (p = 0.057) Controls: 216 ± 9.5 Nm Lepley 2015, Scand J Med Sci Sports Quadriceps LSI: Presurgery: 80.4% 6 months post-aclr: 92.5% Insufficient (per healthy controls) at 6 months post-aclr despite acceptable LSI > 90% Hiemstra 2007, Clin Biomech (Bristol, Avon) 3.5 years post-aclr Symmetric at all eccentric and concentric velocities Insufficient (per healthy controls) at all eccentric and concentric velocities Lynch 2013, J Orthop Sports Phys Ther 1 month post-injury Performance Measures N=188; 63% men Normal quad index (>90%) but bilateral quad activation failure Rohman 2015, Am J Sports Med

7 No worsening of uninvolved limb measures between 4 months and 6 months post-aclr Limitation: Fails to account for uninvolved limb changes between ACL injury and 4 months post-aclr Gokeler 2017, Orthop Traumatol Surg Res N=52; 7 months post-aclr 38 men (23.9±3.5 years); 14 women (21.7±3.5 years) Compared both limbs to previous normative data (Myers 2014; Gustavsson 2006) Matched for sex, age, type of sport Interlimb differences for single hop (men & women) and triple hop (men only) Both limbs lower than norms for single and triple hop Performance Measures & Quadriceps Strength Wellsandt 2017, J Orthop Sports Phys Ther 57% achieved 90% LSI s (quad + hops) 29% achieved 90% of pre-operative uninvolved limb function (EPIC) 34% who met 90% LSI s did not meet 90% EPIC measures 8 of 11 (4 ipsi, 4 contra) second ACL injuries achieved 90% LSI s 6 of these 8 failed 90% EPIC Zwolski 2016, Am J Sports Med 45 female patients (15 ACLR-U, 15 ACLR-B, 15 controls) Completed testing after RTS clearance Both limbs in ACLR-B and involved limb in ACLR-U had significantly lower quad strength than the uninvolved limb in ACLR-U and both limbs of control subjects Alternate RTS Benchmarks: Collection of pre-injury data Provides patient-specific data of functional and performance levels before injury Limitations: Time Equipment and resources Determination of important measures Unrealistic in most practice settings

8 Normative data: Limitations: Not widely developed Lack comparisons for body size, sport position, ect. De Carlo 1997 (J Sport Rehabil): Hop tests in high school athletes Myers 2014 (Int J Sports Phys Ther): Hop tests in high school and collegiate basketball and soccer players More stringent than 90% LSI s Does 90% equal sufficient? 10% considered to account for normal interlimb asymmetry Myer 2011 (J Orthop Sports Phys Ther), Wilk 1994 (J Orthop Sports Phys Ther) Schmitt 2016 APTA-CSM Proceedings RTS Test Battery N=97 patients (91% female); mean 17.2 years Successful Sports Participation: 1 year post-rts Tegner score >RTS Tegner score IKDC > 95% & Single Hop for Distance > 95% 5.4 times more likely to achieve successful sports participation 6.9 times more likely in female patients No single test encompasses all domains needed for return to sport (Adams 2012 J Orthop Sports Phys Ther) Additional measures beyond strength & hops may be needed Lentz 2012 (J Orthop Sports Phys Ther): 55% return to sports at 1 year post- ACLR No knee effusion, no instability episodes, IKDC >93% had greatest likelihood to return to sport Paterno 2017 (Sports Health): Activity and 2 nd ACL injury after RTS TSK-11 17: 4X more likely to have lower activity levels TSK-11 19: 13X more likely to have 2 nd ACL injury within 24 months Post-Operative ACL Protocols Include bilateral strengthening and performance training Progressive and targeted bilateral training, especially after symmetry attained

9 Longer return-to-sport progressions Reinjury rate decreased 51% for every month RTS was delated (up until 9 months) Grindem 2016 Br J Sports Med CONCLUSIONS: Both symmetric and sufficient strength and performance are important Both limbs need to be trained during post-operative rehab Optimal Return-To-Sport Criteria??? o o o Goal: Successful return to sport without further injury Exact benchmarks to aim for still unknown BUT-----Objective testing works! Minimum: Strength and hop performance testing REFERENCES: Grindem, H., et al. (2016). "Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study." Br J Sports Med 50(13): Kyritsis, P., et al. (2016). "Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture." Br J Sports Med 50(15): Paterno, M. V., et al. (2010). "Biomechanical measures during landing and postural stability predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and return to sport." Am J Sports Med 38(10): Toole, A. R., et al. (2017). "Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs?" J Orthop Sports Phys Ther 47(11): Schmitt, L. C., et al. (2012). "The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction." J Orthop Sports Phys Ther 42(9): Ithurburn, M. P., et al. (2018). "Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later." Knee Surg Sports Traumatol Arthrosc 26(2): Logerstedt, D., et al. (2012). "Single-legged hop tests as predictors of self-reported knee function after anterior cruciate ligament reconstruction: the Delaware-Oslo ACL cohort study." Am J Sports Med 40(10):

10 Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: A systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7): Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of secondary injury in younger athletes after anterior cruciate ligament reconstruction: A systematic review and meta-analysis. Am J Sports Med Appell HJ. Can experimental immobilization studies predict the clinical process after orthopedic surgery? Int J Sports Med. 1993;14(5): Thom JM, Thompson MW, Ruell PA, et al. Effect of 10-day cast immobilization on sarcoplasmic reticulum calcium regulation in humans. Acta Physiol Scand. 2001;172(2): Lepley LK, Palmieri-Smith R. Quadriceps strength, muscle activation failure, and patientreported function at the time of return to activity in patients following anterior cruciate ligament reconstruction: A cross-sectional study. J Orthop Sports Phys Ther. 2015;45(12): Pietrosimone BG, Lepley AS, Ericksen HM, Clements A, Sohn DH, Gribble PA. Neural Excitability Alterations After Anterior Cruciate Ligament Reconstruction. J Athl Train Jun;50(6): Lynch AD, Logerstedt DS, Axe MJ, Snyder-Mackler L. Quadriceps activation failure after anterior cruciate ligament rupture is not mediated by knee joint effusion. J Orthop Sports Phys Ther. 2012;42(6): Urbach D, Nebelung W, Weiler HT, Awiszus F. Bilateral deficit of voluntary quadriceps muscle activation after unilateral ACL tear. Med Sci Sports Exerc Dec;31(12): Hart JM, Turman KA, Diduch DR, Hart JA, Miller MD. Quadriceps muscle activation and radiographic osteoarthritis following ACL revision. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2011;19: Hiemstra LA, Webber S, MacDonald PB, Kriellaars DJ. Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft. Clin Biomech (Bristol, Avon). 2007;22: Rohman E, Steubs JT, Tompkins M. Changes in involved and uninvolved limb function during rehabilitation after anterior cruciate ligament reconstruction: Implications for limb symmetry index measures published online march ]. Am J Sports Med. 2015:1-8. Gokeler A, Welling W, Benjaminse A, Lemmink K, Seil R, Zaffagnini S. A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: A case control study. Orthop Traumatol Surg Res Oct;103(6): Wellsandt E, Failla MJ, Snyder-Mackler L. Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury. J Orthop Sports Phys Ther. 2017;47(5): Zwolski C, Schmitt LC, Quatman-Yates C, Thomas S, Hewett TE, Paterno MV. The influence of quadriceps strength asymmetry on patient-reported function at time of return to sport after anterior cruciate ligament reconstruction. Am J Sports Med. 2015;43(9): Sell DM. Normative data for range of motion and singleâ leg hop in high school athletes. J Sport Rehabil. 1997;6: Myers BA, Jenkins WL, Killian C, Rundquist,P. Normative data for hop tests in high school and collegiate basketball and soccer players. Int J Sports Phys Ther. 2014;9(5):

11 14. Adams D, L. Current concepts for anterior cruciate ligament reconstruction: A criterionbased rehabilitation progression. J Orthop Sports Phys Ther Lentz TA, Zeppieri G Jr, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL. Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther Nov;42(11): Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study. Sports Health Dec 1: doi: / [Epub ahead of print]