Return To Sports After ACL Reconstruction JBJS - and - JOSPT - Articles

685
C OPYRIGHT 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Current Concepts Review
Operative Treatment of Primary Anterior

Cruciate Ligament Rupture in Adults
Christopher D. Murawski, BS, Carola F. van Eck, MD, PhD, James J. Irrgang, PT, PhD, ATC, FAPTA,
Scott Tashman, PhD, and Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Investigation performed at the Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Operative management of an acute anterior cruciate ligament (ACL) rupture may be required in young and active
patients to stabilize the knee and return patients to desired daily activities.
ACL reconstruction should be performed anatomically.
The majority of studies show no differences between anatomic single-bundle and double-bundle ACL reconstruction with respect to patient-reported outcome scores. Double-bundle reconstruction may provide superior
knee joint laxity measurements compared with the single-bundle technique.
Following ACL reconstruction, the age and activity level of a patient are predictive of his or her time of return to
sports and reinjury.
Concomitant meniscal and/or cartilage damage at the time of surgery, in addition to a persistent knee motion
deficit, are associated with the development of osteoarthritis after ACL reconstruction.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor
reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or
more exchanges between the author(s) and copyeditors.
Anterior cruciate ligament (ACL) rupture is a common injury

worldwide. Estimates suggest an annual incidence for ACL rupture
of thirty-five per 100,000 people of all ages1, with an approximately two to eight-times higher risk in female athletes than in
male athletes2-7. These injuries often result in instability of the
knee, increased joint laxity, and reduced activity and participation, as well as an increased risk of knee osteoarthritis in the
long term8,9. Surgical reconstruction of the ACL is often recommended, particularly in young and active patients, to facilitate a return to the desired daily activities, including sports.
As the estimated annual health-care cost of ACL surgery
is $3 billion in the United States alone, providing patients with the
best potential for a successful outcome after ACL reconstruction
remains a topic of intense interest among clinicians and researchers10. In this review, a critical assessment of the evidence
for operative treatment of primary ACL rupture in adults (eighteen
years of age or older) is provided, including principles for decision
making, clinical outcomes, and guidelines for return to sports.
Anatomy and Function
The ACL is composed of two functional bundles, the anteromedial and posterolateral bundles, which are named for the location of their respective insertion sites on the tibia11,12. The tibial
insertion site of the ACL reveals a characteristic fan-shaped footprint, whereas the femoral insertion site demonstrates a smaller,
oval-shaped appearance13. The femoral insertion site is identifiable
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of
any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of
this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No
author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is
written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:685-94
http://dx.doi.org/10.2106/JBJS.M.00196
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TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O LU M E 96-A N U M B E R 8 A P R I L 16, 2 014
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using the position of two osseous ridges on the medial wall of

the lateral femoral condyle14-18. The lateral intercondylar ridge,
or so-called residents ridge, denotes the anterior border of the
femoral insertion site. The lateral bifurcate ridge runs perpendicular to the lateral intercondylar ridge, between the femoral
insertion sites of the anteromedial and posterolateral bundles19.
Functionally, the anteromedial and the posterolateral bundles
behave synergistically with knee flexion, whereby both anteroposterior and rotational stability of the knee are provided. Individually, the anteromedial bundle length remains constant
throughout the knee flexion-extension, attaining peak tension
between 45 and 60 of flexion20-22. In comparison, the posterolateral bundle is tight in extension and loosens with flexion,
thereby allowing axial rotation of the knee to occur. Varying
mechanical behaviors of the functional bundles of the ACL have
been reported23,24.
A thorough understanding of the anatomy and function
of the native ACL is fundamental for the treatment of ACL injuries. This understanding ultimately aids the surgeon in determining the most appropriate treatment strategy for a partial
or complete rupture of the ACL.
O P E R AT I V E T R E AT M E N T O F P R I M A R Y A N T E R I O R
C R U C I AT E L I G A M E N T R U P T U R E I N A D U LT S
Fig. 1
An arthroscopic ruler is used to measure the size of the tibial insertion site
Treatment of ACL Injuries

ACL injuries can be managed with nonoperative or operative
treatment. The decision to recommend operative treatment for
an acute ACL rupture is multifactorial and must be individualized
to each patient on the basis of his or her age25, desired activity
level, and presence of potential concomitant injuries. In general,
younger and more active patients are more likely to require surgery to return to functionally demanding activities. In the remainder of this review article, we focus on operative treatment
of ACL injuries. While rehabilitation after ACL reconstruction
is an important aspect of the ultimate success after ACL reconstruction25-28, it is not a focus of this review.
Operative Treatment
Once the decision to proceed with operative treatment of an ACL
rupture is made, timing of the procedure becomes an important
variable to consider. Preoperative range of motion, swelling,
and quadriceps strength have been investigated as factors that
can affect the ultimate success of ACL reconstruction29,30. Preoperative swelling and limited range of motion have been related to
the development of arthrofibrosis after surgery 29.
Preoperative quadriceps strength deficits of >20% have
been shown to significantly affect the two-year functional outcome of ACL reconstruction with bone-patellar tendon-bone
autograft30. Moreover, it has been reported that preoperative
quadriceps strength of >90% of that of the noninjured leg significantly increased postoperative strength two years after surgery compared with those with <75% of preoperative quadriceps
strength31. Rehabilitation prior to surgery should focus on regaining range of motion, reducing swelling, and strengthening
the quadriceps.
Intraoperatively, the rupture pattern of the ACL should be
confirmed, and if a partial one-bundle rupture is evident, augmentation surgery should be considered32. Partial ACL ruptures
in the sagittal plane, with the ACL tibial footprint shown dissected and the
anteromedial (AM) and posterolateral (PL) bundles marked with a standard, commercially available, arthroscopic radiofrequency ablation device.
have been reported to occur in approximately 5% to 35% of

patients32,33. Performing a one-bundle augmentation surgery carries the theoretical advantages of maintaining proprioceptive
fibers, biomechanical strength, and biological healing potential34.
Careful dissection and preservation of the native insertion sites
can facilitate determination of the appropriate tunnel location(s).
Presently, the majority of surgeons who perform ACL reconstructions do so using a single-bundle technique. The doublebundle technique is more commonly utilized in Europe and
Asia than it is in the United States. Regardless, it is important to
understand the double-bundle anatomy of the ACL so that surgeons can perform an anatomic single-bundle or double-bundle
ACL reconstruction. In the event that a surgeon has experience
in performing double-bundle ACL reconstruction and considers
this as part of the preoperative planning process, the decision to
perform anatomic single-bundle or double-bundle ACL reconstruction is based on several criteria. A comprehensive flowchart
to assist surgeons in this decision has been previously described35.
The variation in size of the tibial insertion site is one element to
consider36 (Fig. 1). A tibial insertion site size of <14 mm, measured
arthroscopically, makes it difficult to perform a double-bundle
reconstruction35. Furthermore, arthritic changes, multiligament
injury, severe bone bruising, open physes, and a narrow notch
width are considered indications to perform single-bundle reconstruction32. Variation in the shape of the notch can also
influence whether two femoral tunnels can be drilled safely for
double-bundle reconstruction37.
Typical graft options for ACL reconstruction include bonepatellar tendon-bone autograft, hamstring tendon autograft, quadriceps tendon autograft, and allograft (Table I)38-40. Of these options,
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TABLE I Advantages and Disadvantages of Available Graft Choices for ACL Reconstruction
Graft Choice
Bone-patellar tendon-bone
Hamstring
Quadriceps tendon
Allograft
Advantages
Disadvantages
Bone-to-bone healing in both tunnels
Not suitable for double-bundle reconstruction
Comparable stiffness to native ACL
Risk of anterior kneeling pain
Invasive, large incision
Risk of patellar fracture
Fixed length
Weaker than native ACL
Ease of harvest
Soft-tissue healing
Cosmesis
Graft size can be unpredictable
Minimal donor site morbidity
Comparable strength to native ACL
Not suitable for certain athletes who rely

heavily on their hamstring muscles
Less stiffness than native ACL

Invasive, large incision
Large graft
Can be used for single or

double-bundle reconstruction
Risk of patellar fracture
Option of a one-sided bone block
No donor site morbidity
Theoretical risk of disease transmission
Available in various types and sizes
Longer healing time
Increased risk of rerupture, especially in younger

patients and irradiated grafts
bone-patellar tendon-bone graft is not suitable for double-bundle

reconstruction. For the purposes of preoperative planning, the
sagittal thickness of the patellar and quadriceps tendons can be
measured on magnetic resonance imaging (MRI) scans to provide the surgeon with an idea as to potential graft size41. Studies
have also evaluated the use of MRI in predicting hamstring graft
size and have found that, while cross-sectional area measurements
on MRI scans correlate positively with intraoperative graft size42,43,
measurements of graft diameter do not42. Magnussen et al. found
that a hamstring autograft size of 8 mm in diameter was associated with a higher rate of early revision than were those of
>8 mm44. In patients having primary surgery, allograft may be
used when there are concerns of donor site morbidity or cosmesis. Fresh-frozen allografts are typically preferred over irradiated, chemically processed, or preserved grafts and provide
results equal to those of autografts45-47. Recent studies have,
however, indicated higher rates of graft failure following ACL
reconstruction with varying types of allograft, particularly in
younger active individuals desiring an early return to sport48-51.
Ultimately, daily activities and patient lifestyle influence
graft choice for an individual undergoing ACL reconstruction.
For example, in a patient with daily activities that include kneeling
(e.g., wrestling or religious practices), the use of a bone-patellar
tendon-bone autograft may be contraindicated because it is associated with a higher prevalence of anterior knee pain52.
Proper tunnel placement is critical in anatomic ACL reconstruction. Nonanatomic tunnel placement has been previously shown to decrease knee motion53 and to produce abnormal
rotational knee kinematics during dynamic loading54. A recent
study has evaluated the ACL tunnel positions used by twelve
surgeons and found a lack of agreement in the ideal position for

single-bundle ACL tunnels55. Several intraoperative and postoperative methods have been described to evaluate tunnel placement. Postoperatively, anteroposterior and lateral radiographs
Fig. 2
A standard 45 flexion weight-bearing posteroanterior (PA) radiograph,

made one year after single-bundle ACL reconstruction, demonstrating a
45 femoral tunnel angle relative to the long axis of the femur, suggestive
41
of anatomic tunnel placement .
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Fig. 3
Figs. 3-A, 3-B, and 3-C MRI scans of a knee that had an anatomic ACL reconstruction with bone-patellar tendon-bone autograft. Fig. 3-A Preoperative scan
showing initial measurements. The ACL length is also measured preoperatively. Figs. 3-B Sagittal scan, made three months postoperatively, showing
the tibial insertion site size and inclination angle measurements for comparison. Fig. 3-C A coronal oblique sequence, made three months postoperatively,
in the plane of the long axis of the ACL starting at the intercondylar roof of the Blumensaat line. This sequence can be used for graft evaluation after
ACL reconstruction.
can be used to evaluate tunnel angle and implant position.

Illingworth et al. described a femoral tunnel angle measurement based on the long axis of the femur on an anteroposterior
radiograph, whereby an angle of <32.7 is likely to be nonanatomic56 (Fig. 2). Postoperative MRI measurements of the insertion site, inclination angle, and length of the ACL can also
be compared with those made preoperatively (Fig. 3). A threedimensional computed tomography (CT) scan is presently considered the gold standard for evaluation of tunnel placement57-59
(Figs. 4 and 5). Meuffels et al. demonstrated that threedimensional measurements provided the highest reliability in
the evaluation of femoral and tibial tunnel placement60. Moreover, a three-dimensional CT scan can be particularly useful in
planning for knees in which revision surgery may eventually be
required.
Clinical Outcomes After ACL Reconstruction
A Level-I clinical trial by Frobell et al. randomized 121 physically active adults to a structured rehabilitation program with
early ACL reconstruction or to a rehabilitation program alone
with the option of delayed ACL reconstruction61. At the twoyear follow-up, the difference using a subscale of the Knee Injury
and Osteoarthritis Outcome Score (KOOS4) was a mean of 39.2
for the early ACL reconstruction group and a mean of 39.4
points for the rehabilitation and optional delayed reconstruction group (p = 0.96). The rehabilitation and optional delayed
reconstruction group had a higher rate of meniscal surgery than
the early reconstruction group. Similar results were also found
with recently reported five-year results of this trial62. In total, thirty
patients (51%) in the delayed reconstruction group ultimately
had ACL surgery. Therefore, nonoperative management may

be feasible in a well-defined cohort of patients with an acute ACL
tear who have been counseled accordingly.
The outcomes of single-bundle and double-bundle reconstruction have been reported previously (Figs. 6 and 7). A recent
Cochrane review by Tiamklang et al. evaluated the effects of
single-bundle compared with double-bundle reconstructions
in adult patients in seventeen randomized and quasi-randomized
controlled trials63. The authors reported no detectable differences between single-bundle and double-bundle reconstructions in patient-reported outcomes up to five years after surgery.
The two to five-year follow-up evaluation demonstrated improvements in the International Knee Documentation Committee (IKDC) knee examination, pivot-shift test, and knee laxity
measurements on the KT-1000 arthrometer with double-bundle
reconstruction. Single-bundle reconstructions had a higher rate
of new meniscal injury. Importantly, methodological deficiencies
were prevalent in all trials included in the review and should be
considered when evaluating the results of this study.
In a recent Level-I randomized controlled trial by Hussein
et al., anatomic double-bundle ACL reconstruction was compared with anatomic single-bundle and conventional singlebundle ACL reconstructions with hamstring autograft64. Two
hundred and eighty-one patients were prospectively followed
for a mean of 51.15 months after surgery. The patients in the
anatomic double-bundle group had improved anteroposterior
laxity (measured with the KT-1000 arthrometer) and rotational
laxity (pivot-shift test) compared with the anatomic single-bundle
group; the anatomic single-bundle group had improved anteroposterior and rotational laxities compared with conventional
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favoring double-bundle reconstruction. There is also some evidence to suggest that individualized surgery may facilitate similar
outcomes with respect to knee joint laxity, regardless of whether
single or double-bundle reconstruction is performed. Further
investigation is needed to confirm or dispute these findings.
The outcomes after one-bundle augmentation reconstruction for partial rupture of the ACL have been reported in several
series. Sonnery-Cottet et al. reported that reconstruction of the
anteromedial bundle with preservation of the posterolateral bundle
significantly decreased anteroposterior laxity (Telos stress radiography), while significantly increasing the IKDC Subjective
Knee Form and Lysholm scores at a mean follow-up of twentysix months66. Adachi et al. compared ACL augmentation surgery
in partial ACL tears and complete ACL reconstruction with complete ACL tears at a mean follow-up of 2.6 years67. The authors
reported augmentation surgery to be superior for joint stability and position sense. A recent systematic review found that
Fig. 4
Femoral and tibial three-dimensional CT reconstructions demonstrating

anatomic tunnel placement of a single-bundle ACL reconstruction.
single-bundle reconstruction. The only significant difference in

patient-reported outcome was a higher Lysholm score in the
anatomic double-bundle group in comparison with the conventional single-bundle group. There were no significant differences in patient-reported outcome scores in the comparison
of anatomic double-bundle with anatomic single-bundle reconstruction. In a second prospective comparative study (Level II),
anatomic single-bundle reconstructions were compared with
anatomic double-bundle reconstructions with hamstring autograft, with the procedures individualized on the basis of intraoperative measurements of the native ACL tibial insertion
site size65. At a mean follow-up of thirty months after surgery, no
differences between the groups were detected with respect to
the Lysholm and IKDC Subjective Knee Form scores or the results
of the KT-1000 measurements and pivot-shift tests.
The majority of published studies have shown no differences between anatomic single-bundle and double-bundle ACL
reconstruction in terms of patient-reported outcomes. Differences may exist with regard to knee joint laxity measurements,
Fig. 5
Femoral and tibial three-dimensional CT reconstructions demonstrating

anatomic tunnel placement of a double-bundle ACL reconstruction.
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Fig. 6
Figs. 6-A and 6-B Intraoperative arthroscopic photographs demonstrating anatomic tunnel placement for single-bundle ACL reconstruction on the femur and
tibia. Fig. 6-A A dilator is used to enlarge the tibial tunnel. Fig. 6-B A hamstring autograft is then tensioned and fixed in an anatomic position.
the available evidence to support augmentation was weak but

encouraging68.
In Vivo Biomechanics After ACL Reconstruction
In vivo kinematic studies evaluate knee biomechanics without
the time-zero limitation of in vitro studies. They also enable
serial assessment of the effects of healing on knee function after
ACL reconstruction and can involve realistic weight-bearing
activities, such as running, jumping, and stair-climbing.
Georgoulis et al. compared ACL-reconstructed and contralateral, normal knees using conventional video-motion analysis
with surface markers69. While no differences were evident during
walking, greater internal tibial rotation in the reconstructed
knee was observed during more demanding pivoting tasks. Tashman
et al. used dynamic stereoradiography to assess knee kinematics
during the stance phase of downhill running, and found greater
external rotation and adduction in ACL-reconstructed knees
compared with the contralateral, uninjured limbs54. The surgical
technique used for that study incorporated nonanatomic placement of the graft, demonstrating that nonanatomic ACL reconstruction fails to restore preinjury knee function under functional
loading conditions. Abebe et al. utilized biplanar fluoroscopy
and MRI to evaluate knee function during a series of static joint
positions and reported that single-bundle reconstruction with
anatomic femoral tunnel placement resulted in knee joint kinematics that were more closely restored relative to the intact knee
compared with nonanatomic tunnel placement70.
In a separate study, tibiofemoral rotations and translations in knees that had anatomic double-bundle ACL reconstruction were compared with those in the contralateral, normal
knees using a biplane radiographic system during the early to
midstance phase of running71. A model-based tracking method
was also utilized to evaluate tibiofemoral kinematics. No significant or clinically important differences were found between
the ACL-reconstructed and contralateral limbs with regard to
kinematic variables after anatomic double-bundle reconstruction.
Fig. 7
Figs. 7-A and 7-B Intraoperative arthroscopic photographs demonstrating anatomic tunnel placement for double-bundle ACL reconstruction on the femur
and tibia. Fig. 7-A Dilators are used to enlarge the tibial tunnels. Fig. 7-B The anteromedial (AM) and posterolateral (PL) bundles are then tensioned and fixed
with allografts in anatomic positions.
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These results suggest that anatomic double-bundle reconstruction may be effective for restoring knee function compared with
the uninjured side. It is not, however, known whether anatomic
single-bundle reconstruction may produce results similar to anatomic double-bundle reconstruction compared with the contralateral knee.
Return to Sports After ACL Reconstruction
The timing of return to sports after ACL reconstruction is multifactorial. Graft choice is an important consideration with regard to whether there is bone-to-bone healing (bone-patellar
tendon-bone graft) or soft tissue-to-bone healing. In a systematic
review and meta-analysis, Ardern et al. assessed forty-eight studies
with a total of 5770 patients at a mean follow-up of 41.5 months
after ACL reconstruction72. In total, while 82% of the patients
reported returning to some level of sporting activity, 63% of the
patients returned to sports participation at the preinjury level,
and only 44% returned to competitive sports. The leading reason
given for not returning to sporting activity was fear of reinjury.
Brophy et al. evaluated the return to sports among soccer
athletes and found that younger or male athletes were more likely
to return to play than were older or female athletes73. Smith et al.,
who separately evaluated the return to the preinjury activity level
among seventy-seven competitive athletes with a mean age of
twenty-one years (range, fifteen to thirty years), found that 71%
(fifty-five) returned to preinjury activity levels by twelve months
after surgery74. Further research on return to sports should evaluate the rate of return to the preinjury activity in terms of the type,
frequency, intensity, and duration of participation.
Graft Failure After ACL Reconstruction
Graft failure in the ipsilateral knee after ACL reconstruction and
native ACL rupture in the contralateral knee have been investigated. A recent study from the Danish Knee Ligament Reconstruction Register compared anteromedial with transtibial femoral
tunnel drilling during ACL reconstruction. Anteromedial drilling had a higher overall rate of revision surgery (5.16%) than
transtibial drilling (3.20%), with a relative risk of 2.04 (95% confidence interval, 1.39 to 2.99)75. Surgeons should use caution when
evaluating these results, given the tendency of the transtibial
technique to place the graft in a nonanatomic position. Individuals undergoing anatomic ACL reconstruction may be at higher
risk for graft failure, particularly with early return to activity,
given the higher, closer to normal, in situ forces on an anatomically placed graft76,77.
A recent study by Bourke et al. of patients undergoing ACL
reconstruction with either bone-patellar tendon-bone or hamstring autograft found graft failure to be 11%, while contralateral
ACL rupture was 13%78. Graft choice did not affect failure rate.
Other authors have also reported a higher risk of failure in the
contralateral ACL compared with the ipsilateral graft79. Shelbourne
et al. followed 1415 patients for a minimum of five years after
ACL reconstruction with bone-patellar tendon-bone autograft
and found a lower patient age and higher activity level to be
associated with increased injury to either knee80. Returning
to activity before six months postoperatively did not appear to
increase the risk for injury. In this particular study, the group
with an age of less than eighteen years returned at a mean 4.6
months after surgery. In a prospective analysis of failure in
anatomic ACL reconstruction with allograft, van Eck et al. found
that 48% (thirteen) of twenty-seven reruptures occurred within
nine months after surgery, before the patients had received
clearance to return to sports51. Further investigation is required
to determine factors affecting ACL graft failure, including
consideration for graft healing. On the basis of the available
evidence, a lower patient age and higher activity level, but not
time to return to sport, appear to be predictive of reinjury.
Osteoarthritis After ACL Reconstruction
The development of osteoarthritis after ACL reconstruction is a
concern. Li et al. retrospectively investigated the predictors of
radiographic knee osteoarthritis after nonanatomic single-bundle
ACL reconstruction81. Radiographic osteoarthritis, defined as Kellgren
and Lawrence grade-2 changes in at least one compartment or
grade-1 changes in at least two compartments, were demonstrated
by 39% (ninety-six) of 249 patients at a mean 7.86 years followup. The most optimal set of predictors for osteoarthritis were
body mass index, length of follow-up, prior medial meniscectomy,
and medial chondrosis of grade 2 or greater. Separately, Roe
et al. investigated differences in osteoarthritis rates in a consecutive cohort of nonrandomized patients who underwent ACL
reconstruction with hamstring or bone-patellar tendon-bone
autograft82. At seven years of follow-up, 45% (twenty-four) of fiftythree patients in the bone-patellar tendon-bone group and 14%
(seven) of fifty-one in the hamstring group showed signs of radiographic osteoarthritis (p = 0.002).
Several studies with longer-term follow-up have also been
performed. Oiestad et al. prospectively evaluated knee function
and the prevalence of osteoarthritis in patients ten to fifteen
years after isolated ACL reconstruction and in patients who had
concomitant meniscal and/or cartilage pathology 83. Radiographic
assessment using the Kellgren and Lawrence classification system
revealed that 80% of the patients in the concomitant pathology
group had joint space narrowing of grade 2 or greater compared
with 62% in the isolated group (p = 0.008). However, differences
were not detectable between groups with respect to symptomatic
osteoarthritis. In a separate study of the same cohort, Oiestad et al.
reported that the prevalence of patellofemoral osteoarthritis was
26.5% (forty-eight of 181 patients twelve years after reconstruction)
and was associated with older age, increased symptoms, and greater
tibiofemoral osteoarthritis, as well as reduced knee function84.
Salmon et al. also reported an association between degenerative joint changes and meniscectomy, increased knee
joint laxity, and loss of knee motion thirteen years after ACL
reconstruction with bone-patellar tendon-bone autograft85. Similarly, Shelbourne et al. evaluated 780 patients undergoing ACL
reconstruction with bone-patellar tendon-bone autograft and,
at a minimum of five years of follow-up, found that the loss of
normal knee flexion and extension was associated with an increased
rate of radiographic osteoarthritis86. In two separate studies of
patients in whom concomitant knee pathology was absent at
the time of surgery, Shelbourne and Gray and Lebel et al. reported
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TABLE II Grades of Recommendation for Operative Treatment of

Primary Anterior Cruciate Ligament Rupture in Adults
Recommendation
Grade of Evidence*
Operative treatment
Single-bundle reconstruction
Double-bundle reconstruction
Autograft
Allograft
*Grade A indicates good evidence (Level-I studies with consistent

findings) for or against recommending the intervention; Grade B,
fair evidence (Level-II or III studies with consistent findings) for or
against recommending the intervention; Grade C, conflicting or
poor-quality evidence (Level-IV or V studies) not allowing a recommendation for or against the intervention; and Grade I, there is
89
insufficient evidence to make a recommendation .
that the rate of osteoarthritis was 2% and 8%, respectively, beyond

the mean follow-up time of ten years87,88.
It is the general consensus of the available evidence that
meniscal and/or cartilage damage and knee motion deficits after
surgery are associated with the development and/or progression of osteoarthritis after ACL reconstruction. Furthermore,
patients without concomitant joint pathology at the time of
ACL surgery appear to have a low rate of osteoarthritis, even at
relatively long-term follow-up. Continued investigation into the
cause and development of osteoarthritis after ACL reconstruction,
including early recognition via advanced imaging modalities or

identification of relevant biomarkers, will be important.
In conclusion, operative management of acute ACL rupture
is common in young and active patients and can achieve predictable outcomes (Table II). The use of double-bundle reconstruction appears to provide no difference compared with
single-bundle reconstruction in patient-reported outcomes. The
age and activity level of the patient are predictive of the return to
sports and of reinjury. On the basis of the currently available
data, the time to return to sports may not be predictive of reinjury
to the reconstructed ACL. Meniscal and/or cartilage pathology
noted at the time of ACL reconstruction, as well as a knee motion
deficit postoperatively, are associated with the development
and/or progression of osteoarthritis. Future studies investigating
operative methods for the treatment of ACL injuries are warranted. It is imperative that these studies be adequately powered
and use patient-relevant and sensitive outcome measures. n
Christopher D. Murawski, BS
Carola F. van Eck, MD, PhD
James J. Irrgang, PT, PhD, ATC, FAPTA
Scott Tashman, PhD
Freddie H. Fu, MD, DSc(Hon), DPs(Hon)
Department of Orthopaedic Surgery,
University of Pittsburgh School of Medicine,
3471 Fifth Avenue, Suite 1011,
Pittsburgh, PA 15213.
E-mail address for F.H. Fu: ffu@upmc.edu.
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research report
Journal of Orthopaedic & Sports Physical Therapy

Downloaded from www.jospt.org at JOSPT on August 20, 2014. For personal use only. No other uses without permission.
Copyright 2012 Journal of Orthopaedic & Sports Physical Therapy. All rights reserved.
TREVOR A. LENTZ, PT1 GIORGIO ZEPPIERI, JR., PT1 SUSAN M. TILLMAN, PT2 PETER A. INDELICATO, MD3
MICHAEL W. MOSER, MD3 STEVEN Z. GEORGE, PT, PhD4 TERESE L. CHMIELEWSKI, PT, PhD5
Return to Preinjury Sports Participation

Following Anterior Cruciate Ligament
Reconstruction: Contributions
of Demographic, Knee Impairment,
and Self-report Measures
TTSTUDY DESIGN: Cross-sectional cohort.
TTOBJECTIVES: (1) To examine differences in
clinical variables (demographics, knee impairments, and self-report measures) between those
who return to preinjury level of sports participation
and those who do not at 1 year following anterior
cruciate ligament reconstruction, (2) to determine the factors most strongly associated with
return-to-sport status in a multivariate model, and
(3) to explore the discriminatory value of clinical
variables associated with return to sport at 1 year
postsurgery.
TTBACKGROUND: Demographic, physical impair-
ment, and psychosocial factors individually prohibit

return to preinjury levels of sports participation.
However, it is unknown which combination
of factors contributes to sports participation status.
TTMETHODS: Ninety-four patients (60 men; mean
age, 22.4 years) 1 year postanterior cruciate ligament reconstruction were included. Clinical variables were collected and included demographics,
knee impairment measures, and self-report questionnaire responses. Patients were divided into yes
return to sports or no return to sports groups
based on their answer to the question, Have you
returned to the same level of sports as before
your injury? Group differences in demographics,
knee impairments, and self-report questionnaire
responses were analyzed. Discriminant function
analysis determined the strongest predictors of
group classification. Receiver-operating-char-
acteristic curves determined the discriminatory

accuracy of the identified clinical variables.
TTRESULTS: Fifty-two of 94 patients (55%) report-
ed yes return to sports. Patients reporting return to

preinjury levels of sports participation were more
likely to have had less knee joint effusion, fewer episodes of knee instability, lower knee pain intensity,
higher quadriceps peak torque-body weight ratio,
higher score on the International Knee Documentation Committee Subjective Knee Evaluation Form,
and lower levels of kinesiophobia. Knee joint
effusion, episodes of knee instability, and score on
the International Knee Documentation Committee
Subjective Knee Evaluation Form were identified as the factors most strongly associated with
self-reported return-to-sport status. The highest
positive likelihood ratio for the yes-return-to-sports
group classification (14.54) was achieved when
patients met all of the following criteria: no knee effusion, no episodes of instability, and International
Knee Documentation Committee Subjective Knee
Evaluation Form score greater than 93.
TTCONCLUSION: In multivariate analysis, the fac-
tors most strongly associated with return-to-sport

status included only self-reported knee function,
episodes of knee instability, and knee joint effusion.
TTLEVEL OF EVIDENCE: Prognosis, level 2b.
J Orthop Sports Phys Ther 2012;42(11):893-901,

Epub 2 August 2012. doi:10.2519/jospt.2012.4077
TTKEY WORDS: ACL, kinesiophobia, return to

sports
nterior cruciate ligament

(ACL) injuries commonly
occur during sportsrelated activities that
require cutting and pivoting, with
over 200000 injuries reported
in the United States each year.23
Most individuals elect to undergo surgical reconstruction following injury to restore knee function and facilitate return
to sports participation.51,56 Although ACL
reconstruction is thought to provide the
athlete with the best opportunity to return to preinjury levels of sports participation,33 recent studies1,2,21,30,38,57 reported
that between 8% and 50% of those with
ACL reconstruction did not return to the
same sports after surgery, even with follow-up times of up to 5 years.31 Moreover,
as many as 70% of individuals previously
involved in contact sports were unable
to return to the same sports after sur-
Staff Physical Therapist, Shands Rehab Center, University of Florida Orthopaedics and Sports Medicine Institute, Gainesville, FL. 2Clinical Coordinator, Shands Rehab Center, University of
Florida Orthopaedics and Sports Medicine Institute, Gainesville, FL. 3Orthopaedic Surgeon, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL. 4Associate
Professor and Assistant Department Chair, Department of Physical Therapy, University of Florida, Gainesville, FL. 5Associate Professor, Department of Physical Therapy, University of Florida,
Gainesville, FL. Dr Chmielewskis effort on this project was supported by a grant from the National Institutes of Health (K01-HD052713) and by the National Center for Medical Rehabilitation
Research. This project was reviewed and approved by the Institutional Review Board at the University of Florida. Address correspondence to Trevor Lentz, Shands Rehab Center, University of
Florida Orthopaedics and Sports Medicine Institute, 3450 Hull Road, Gainesville, FL 32611. E-mail: lentzt@shands.ufl.edu t Copyright 2012 Journal of Orthopaedic & Sports Physical Therapy
1
journal of orthopaedic & sports physical therapy | volume 42 | number 11 | november 2012 | 893
42-11 Lentz.indd 893
10/17/2012 2:58:32 PM

[
gery.47 Of those individuals who did return to their prior sports, up to 21% were
reported to have returned with major
functional limitations that contributed to
a reduced level of performance.49 For example, a study of running backs and wide
receivers in the National Football League
found that almost 80% returned to competition after ACL injury, but player performance, measured by power ratings,
was reduced by one-third.10 Moreover,
22% of the athletes with ACL reconstruction in the National Basketball Association did not return to a sanctioned
National Basketball Association game after surgery and, of those who did return,
44% experienced a decrease in standard
statistical categories and player efficiency
ratings.9 It has been suggested that the
high incidence of poor return-to-sport
outcomes following ACL reconstruction
may be due to a lack of standardized return-to-sport guidelines and incomplete
resolution of physical and psychological
impairments.3,32,36,37
Poor understanding of the important
factors that determine a successful return
to sports has contributed to variability in
return-to-sport criteria.4,29 Many criteria have been developed based on expert
opinion, empirical evidence, or factors
identified as contributors to postoperative self-reported disability following
ACL reconstruction, including number
of injured knee structures,48 quadriceps
strength,32,45,58 knee pain intensity,32,58
knee flexion range of motion (ROM),32
single-leg hop performance,48,55,58 and
pain-related fear of movement/reinjury.11,30-32 Although these factors have been
associated with self-reported knee function, it is unclear if they influence return
to preinjury levels of sports participation
following ACL reconstruction. Furthermore, the relative importance of these
factors is unknown. To our knowledge,
no study to date has examined demographic, knee impairment, and psychosocial measures in a multivariate model
to determine the most important factors
associated with return to preinjury levels
of sports participation.
research report
Understanding differences between
individuals who do or do not return to
sport after ACL reconstruction is the next
step toward developing evidence-based
return-to-sport rehabilitation guidelines
and participation criteria. The purposes
of this study were (1) to examine differences in clinical variables (demographics, knee impairments, and self-report
measures) between those who return to
preinjury level of sports participation
and those who do not at 1 year following
ACL reconstruction, (2) to determine
the factors most strongly associated with
return-to-sport status in a multivariate
model, and (3) to explore the discriminatory value of clinical variables associated
with return to sport at 1 year postsurgery. Based on previous literature, we
hypothesized that a combination of demographic, knee impairment, functional,
and psychosocial measures would differ
and discriminate between those who did
and did not return to sports.
METHODS
Patients
onsecutive patients with ACL

reconstruction seen for routine
physician follow-up at 1 year postsurgery at the University of Florida
Orthopaedics and Sports Medicine Institute, Gainesville, FL, were eligible to
participate. Patients were enrolled over a
3-year period between September 2007
and September 2010. Inclusion criteria
were (1) unilateral arthroscopic ACL
reconstruction, (2) age between 15 and
50 years, (3) time from injury to surgery of 12 months or less, and (4) preinjury score of 5 or greater on the Tegner
activity-level scale. Our age group was
chosen to include individuals most likely
to be involved in sports-related activities
and undergo ACL reconstruction following ACL injury. We specified a preinjury
Tegner activity level of at least 5 to target
a population of patients who were, at a
minimum, involved in recreational sports
prior to injury. Potential patients were excluded if they had (1) bilateral knee in-
]
jury, (2) prior knee ligament injury and/
or surgery, (3) concomitant ligamentous
injury greater than grade I, (4) articular
cartilage repair procedure performed in
conjunction with ACL reconstruction, or
(5) inability to return to sports following
surgery due to social reasons (too little
time to participate in sports or a change
in lifestyle).31 In communities with a high
prevalence of college students, such as the
one from which the present sample was
drawn, it has been observed that some
individuals choose not to return to sport
due to too little time to participate in
sports or to a change in lifestyle (they attend graduate school, graduate, get a job,
start a family, etc). As a result, many of
these individuals may not have the motivation or potential to return to sport due
to influences other than their physical or
psychological capabilities. Other exclusion criteria were chosen because they
represent additional injuries or surgical
procedures that may significantly affect
the course of rehabilitation or functional
outcome.48 Patients provided written informed consent, and the protocol for the
study was approved by the University of
Florida Institutional Review Board.
Surgical Procedure and Rehabilitation

Program
All surgical procedures were performed
arthroscopically by a board-certified orthopaedic surgeon (P.A.I. or M.W.M.),
using autograft or allograft tissue. The
autograft sources were bone-patellar
tendon-bone or semitendinosus and
gracilis tendons. The allograft sources
were tibialis anterior, tibialis posterior, or
Achilles tendon. The surgical procedure,
as well as graft selection process, for our
surgeons has been previously published.13
Rehabilitation was not controlled in this
study; however, the standard ACL reconstruction rehabilitation protocol used in
our facility and given to patients undergoing rehabilitation at outside facilities
allows for immediate weight bearing and
knee motion as tolerated. The emphasis of the first 6 weeks of rehabilitation
is on decreasing knee effusion, develop-
894 | november 2012 | volume 42 | number 11 | journal of orthopaedic & sports physical therapy
10/17/2012 2:58:33 PM

ing quadriceps control, and regaining

full knee motion. The next 6 weeks of
rehabilitation are focused on increasing
lower extremity muscle strength, muscle
endurance, and neuromuscular control.
Straight-ahead running is permitted at
12 weeks if (1) quadriceps strength symmetry index is greater than 60%, (2) knee
effusion is trace or less, (3) knee extension ROM is equal to the contralateral
side, (4) knee flexion ROM is within 5
of the contralateral side, and (5) average knee pain is less than 2/10. Agility
exercises are initiated at 18 weeks postsurgery following successful completion
of a straight-ahead running program.
Patients are allowed to return to sport
when the following criteria are met: (1)
knee ROM equal to the contralateral side,
(2) quadriceps strength greater than 85%
of the opposite knee based on isokinetic
testing, (3) no knee effusion, and (4)
completion of an agility and sport-specific program. These criteria are typically
met around 6 months postsurgery.
Testing Overview
Patients were tested at a routine 1-year
clinical follow-up visit. A standardized
testing protocol consisted of the collection of demographic information, knee
impairment measures, and self-report
questionnaire responses. Testers were
physical therapists with an average of
10.3 years (range, 5-17 years) of experience in sports physical therapy. Data
were recorded on standard forms and
entered into an electronic database (Microsoft Access 2007; Microsoft Corporation, Redmond, WA).
Demographic Information
Demographic information included age,
sex, weight, time from injury to surgery,
graft type (autograft or allograft), concomitant knee injuries, and time from
surgery to follow-up. Concomitant injuries were diagnosed during the preoperative physician evaluation or during
surgery, and included meniscal injuries,
chondral lesions, and collateral ligament
injuries.
Knee Impairment Measures

Knee Effusion Knee effusion was as-
sessed with the stroke test and graded on

a 5-point scale (none, trace, 1+, 2+, and
3+).50 This method of assessing knee effusion has a substantial interrater reliability ( = 0.75).50
Knee ROM Knee flexion and extension
passive ROM were measured in both
the nonsurgical and surgical sides using a standard goniometer. Side-to-side
knee flexion and extension ROM deficits
were calculated (nonsurgical-side ROM
minus surgical-side ROM). Intertester
reliability has been shown to be high for
measurements of knee flexion ROM (intraclass correlation coefficient [ICC] =
0.98) and knee extension ROM (ICC =
0.89-0.93) using a standard goniometer.8
Knee Ligament Laxity Testing To assess
the integrity of the ACL graft, anterior
displacement of the tibia was measured
with a KT1000 knee ligament arthrometer (MEDmetric Corporation, San Diego,
CA). The tibia was pulled to the end point
of anterior translation while the knee was
flexed to approximately 30. The amount
of anterior displacement was recorded in
millimeters. Two trials were performed
on each side and averaged. The difference in values between the surgical and
nonsurgical sides was recorded as the
anterior knee joint laxity difference. The
KT1000 has been shown to provide valid44,46 and reliable measurements of anterior knee joint laxity (ICC = 0.91-0.93).7
Quadriceps Strength Testing Knee extensor (quadriceps) strength was assessed with an isokinetic dynamometer
(Biodex System 3; Biodex Medical Systems, Shirley, NY). Prior to testing, patients were given a 5-minute warm-up
on a stationary bicycle. They were then
seated and stabilized with a lap-andthigh belt. The dynamometer arm was
set to move through a range of 90 to 0
of knee motion at a speed of 60/s. Testing was conducted on the nonsurgical
side first. Patients performed 2 practice
trials followed by 5 maximal-effort trials.
Testing was then repeated on the surgical side. The peak knee extensor torque
of 5 trials was recorded for each side. Two

separate measures of quadriceps muscle
performance were calculated. First, a
quadriceps symmetry index was calculated by normalizing the peak knee extensor torque on the surgical side to that
of the nonsurgical side and multiplying
by 100. Second, the knee extensor torquebody weight ratio was calculated by dividing knee extensor peak torque (ftlb)
of the surgical side by the subjects body
weight (lb). Isokinetic strength testing
has been shown to be a reliable method of quadriceps strength testing (ICC
= 0.81-0.97)7 and sensitive to strength
changes in the first 2 years following ACL
reconstruction.45
Self-report Questionnaires
Tegner Activity-Level Scale The Tegner
activity-level scale is an 11-point grading scale for work and sports activities.52
The scale rates activity level from 0 (sick
leave or disability pension because of
knee problems) to 10 (competitive sports
such as soccer, football, or rugby at the
national or elite level). Level 5 indicates
participation in sport-related activities
at the lowest recreational level. The scale
was initially developed to measure activity following knee ligamentous injury and
has been validated for use following ACL
injury.6 The Tegner scale has demonstrated acceptable test-retest reliability (ICC
= 0.80) after ACL reconstruction.6 At the
time of follow-up testing, patients were
asked to rate their current level of sports
participation as well as to recall their preinjury level of sports participation.
Knee Pain Intensity Knee pain intensity was assessed with an 11-point visual
numeric rating scale. Pain intensity ratings ranged from 0 (no pain) to 10 (worst
imaginable pain). Patients were asked
to rate their worst and best pain levels
over the past 24 hours. They were also
asked to rate their current level of pain.
All 3 pain ratings were averaged to get a
composite knee pain intensity score. The
numeric rating scale has been shown to
be a reliable method of pain intensity assessment (ICC = 0.74-0.76).14,34
10/17/2012 2:58:35 PM

Episodes of Knee Instability Patients
were asked, How many episodes of giving way or buckling at the knee have
occurred since your surgery? Possible
answers included 0, 1, 2 to 5, and greater
than 5.
Tampa Scale for Kinesiophobia Kinesiophobia, or fear of movement/reinjury,
was measured with the shortened version
of the Tampa Scale for Kinesiophobia
(TSK-11).59 Response items are related
to somatic sensations (eg, Pain always
means I have injured my body) and
activity avoidance (eg, Im afraid that I
might injure myself if I exercise). Scores
on the TSK-11 range from 11 to 44 points,
with higher scores indicating greater
pain-related fear of movement/reinjury.
Good test-retest reliability (ICC = 0.81
and 0.93)20,59 has been reported for the
TSK-11 in patients with chronic low back
pain. The TSK-11 is a psychometrically
stable instrument to assess fear of movement/reinjury in the later stages of rehabilitation following ACL reconstruction.19
International Knee Documentation
Committee Subjective Knee Evaluation
Form Knee function was measured with
the International Knee Documentation

Committee Subjective Knee Evaluation Form (IKDC). The IKDC contains
10 items related to knee symptoms and
physical function.26 Scores range from 0
to 100, with higher scores indicating less
disability. An ICC of 0.94 and a standardized response mean of 0.94 have been reported for the IKDC across a broad range
of knee pathologies, including ACL injury
and ACL reconstruction.26,27
Return-to-Sport Status All patients were
asked 2 questions regarding their returnto-sport status: (1) Have you returned to
sports or recreational activities since your
surgery? and (2) Have you returned to
the same level of sports as before your injury? Because our purpose was to specifically examine return to preinjury levels
of sports participation, patients were divided into return-to-sport-status groups
based on their answer to the question,
Have you returned to the same level of
sports as before your injury? Those who
research report
TABLE 1
Measure
Demographic Variable Means and

Distributions for Y-RTS and N-RTS Groups*
Y-RTS (n = 52)
N-RTS (n = 42)
Total (n = 94)
P Value
.44
Injury to surgery, d
70.6 56.6
80.4 66.5
75.0 61.0
Preinjury Tegner score
8.4 1.6
8.3 1.6
8.4 1.5
.76
Postsurgical Tegner score
8.3 1.6
6.6 1.8
7.5 1.9
<.001
Surgery to follow-up, wk
50.9 4.0
49.5 5.7
50.2 4.8
.17
Abbreviations: N-RTS, patients indicating they had not returned to preinjury levels of sports participation; Y-RTS, patients indicating they had returned to preinjury levels of sports participation.
*Values are mean SD.
Significance of difference between Y-RTS and N-RTS group means.
TABLE 2
Distribution of Self-reported Primary

Reasons for Not Returning to Preinjury
Levels of Sports Participation
Primary Reason, n
N-RTS, %
Pain
12
Swelling
19
45
Knee instability
10
Muscle weakness
12
Not yet cleared from doctor to return to sports
12
Other
Fear of injury or lack of confidence
Abbreviation: N-RTS, patients indicating they had not returned to preinjury levels of sports participation.
indicated that they had returned to the

same level of preinjury sports participation were designated Y-RTS (yes return to
sports), and those who reported that they
had not returned to the same level were
designated N-RTS (no return to sports).
Patients who reported that they had not
returned to preinjury levels of sports
participation were asked to pick their
primary reason for not having returned
from a list of options that included pain,
swelling, fear of injury or lack of confidence, knee instability, muscle weakness,
not yet cleared from doctor to return to
sports, too little time to participate or had
a change in lifestyle, and other. This answer represented the subjects perceived
reason for not being able to return to the
preinjury level of sports participation.
Statistical Analysis
Statistical analyses were conducted with
SPSS for Windows Version 13.0 (SPSS
Inc, Chicago, IL). Descriptive statistics

were generated for all variables. We analyzed the data in the following steps: (1)
identification of clinical factors that differed between groups based on returnto-sport status, (2) determination of the
factors most strongly associated with
return-to-sport status in a multivariate
model, and (3) testing the discriminatory value of clinical variables associated
with return-to-sport group allocation. An
alpha level of .05 was used for inferential
analyses.
For the first step, independent-samples t tests determined group differences
(Y-RTS versus N-RTS) in continuous
variables, and chi-square tests were used
for categorical variables. If any individual cells were below 5, we used the Fisher
exact test instead of chi-square analysis.
A 2-way repeated-measures analysis of
variance was used to analyze preinjuryto-postsurgical changes in Tegner score
10/17/2012 2:58:36 PM
TABLE 3
Means and Group Differences

for Demographic, Knee Impairment,
and Self-report Variables*

Measure
Y-RTS (n = 52)
N-RTS (n = 42)
Age, y
20.9 8.3
24.2 8.8
.066
Tegner change score
0.1 0.4
1.9 1.6
<.001
Concomitant injuries
0.9 0.8
0.8 0.9
.533
KT1000 difference, mm
2.3 1.2
2.5 1.3
.357
Extension ROM deficit, deg
0.7 1.4
0.9 2.0
.630
Flexion ROM deficit, deg
2.2 3.9
2.1 3.3
.858
Quadriceps index, %
91.2 11.3
86.6 17.3
.150
Knee extensor torque/body weight, %
81.5 17.2
73.9 19.8
.050
0.4 0.6
1.0 1.1
IKDC
93.8 6.3
78.0 15.6
<.001
TSK-11
15.3 4.1
19.6 4.7
<.001
Average knee pain intensity
Sex, n
P Value
.005
.934
Male
33
27
Female
19
15
Yes
No
51
33
Allograft
25
25
Autograft
27
17
Yes
23
31
No
29
11
Knee joint effusion, n
.005
Graft type, n
.271
Knee instability, n
.004
Abbreviations: IKDC, International Knee Documentation Committee Subjective Knee Evaluation

Form (0-100); N-RTS, patients indicating they had not returned to preinjury levels of sports participation; ROM, range of motion; TSK-11, shortened version of Tampa Scale for Kinesiophobia (11-44);
Y-RTS, patients indicating they had returned to preinjury levels of sports participation.
*Data are mean SD unless otherwise indicated.
The postsurgical follow-up Tegner score minus the preinjury Tegner score.
Fisher exact test analysis.
between groups based on return-to-sport

status.
For the second step, discriminant
function analysis (DFA) was performed
to investigate which of the factors identified by comparative analysis in the first
step were predictors of group status in a
multivariate model. To avoid excluding
any potentially discriminating factors, a
liberal statistical criterion (P.15) was
used to determine factors that would be
entered into the DFA. Briefly, DFA is a
technique that classifies variables into
separate functions based on how linear
combinations of the variables predict
differences in functions. In this analysis,
DFA was used to identify a parsimonious set of variables that contributed to

determining a function. Specifically, we
were interested in including variables in
the prediction model with standardized
coefficients of 0.3 or greater in predicting
the derived functions.
For the third step, we tested the ability of the multivariate model identified
by DFA to discriminate between returnto-sport status groups. An a priori decision was made to use receiver operating
characteristic (ROC) curve analyses from
prior unpublished pilot data to determine
the cutoff value for each continuous and
categorical clinical variable that best dif-
ferentiated the 2 return-to-sport outcome

groups.
For statistical analysis, values on the
more favorable side of the cutoff score for
each variable were coded as 1, and the less
favorable values were coded as 0. Group
allocation for return-to-sport outcome
was coded as 1 for Y-RTS and 0 for NRTS. The number of criteria met for the
multivariate model was determined for
each subject. The accuracy of this model
was then determined by computing positive and negative likelihood ratios.
RESULTS
total of 94 patients were included in the study (60 men, 34

women; mean SD age, 22.4
8.6 years). Demographic information
for these patients is presented in TABLE 1.
Eighty-six patients (91%) reported they
had returned to some form of sports or
recreational activity since their surgery;
however, only 52 (55%) reported returning to preinjury levels of sports participation, and these were included in the
Y-RTS group. Forty-two patients (45%)
reported they had not returned to their
preinjury level of sports participation
and were included in the N-RTS group.
Of those patients reporting N-RTS, 45%
(19/42) reported fear of reinjury/lack of
confidence as a primary reason for not
returning to preinjury levels of sports
participation, and knee joint symptoms
(pain, swelling, instability, muscle weakness) collectively accounted for an additional 40% (17/42). Pain (5/42 [12%])
and muscle weakness (5/42 [12%]) were
the most frequently reported knee joint
symptoms. The distributions of primary
reasons for not returning to preinjury
sports participation are presented in
TABLE 2.
Group differences in demographics,
knee impairments, and self-report questionnaire scores are presented in TABLE 3.
There was no significant difference in age
between groups (P = .07). Tegner activitylevel scores decreased from preinjury to
follow-up in both groups; however, this
10/17/2012 2:58:37 PM
[
TABLE 4
research report
Multivariate Model Analysis*

Patients Meeting Criteria, n
Sensitivity
Specificity
Positive
Likelihood
Ratio
1.00
0.00
1.00
Undefined
0.98
0.12
1.11
0.16
23
0.87
0.67
2.60
0.20
27
13
0.35
0.98
14.54
0.67
18

Criteria Met, n
Negative
Likelihood
Ratio
Y-RTS Group
N-RTS Group
Abbreviations: N-RTS, patients indicating they had not returned to preinjury levels of sports participation; Y-RTS, patients indicating they had returned to preinjury levels of sports participation.
*Variables included in the model: no knee joint effusion, no episodes of knee instability, International
Knee Documentation Committee Subjective Knee Evaluation Form (0-100) score greater than 93 (area
under curve, 0.815; P<.001).
decrease was found to be statistically significant in the N-RTS group only. Patients
in the Y-RTS group had less presurgicalto-postsurgical change in Tegner score
(P<.001), lower grade of knee joint effusion (P = .005), fewer episodes of knee
instability (P = .004), lower knee pain
intensity (P = .005), higher quadriceps
peak torque-body weight ratio (P = .050),
higher IKDC score (P<.001), and lower
TSK-11 score (P<.001).
The clinical variables entered into
DFA were knee joint effusion, episodes
of knee instability, knee pain intensity,
quadriceps peak torque-body weight ratio, IKDC score, and TSK-11 score. In this
analysis, a statistically significant function for determination of return-to-sport
status was determined (Wilks = .571,
P<.001). Investigation of the standardized
coefficients indicated that the strongest
contributors to this function were knee
joint effusion (.519), episodes of knee instability (.357), and IKDC score (.788).
The accuracy for the final multivariate model (range of clinical variables,
0-3) is reported in TABLE 4. Based on prior unpublished data, the following cutoff
scores were set for each variable in the
final multivariate model: effusion rated
as none, no episode of instability, and
IKDC score greater than 93. Likelihood
ratio analysis indicated that meeting all
3 of the criteria resulted in a large shift
(positive likelihood ratio, 14.54) in post-
test probability of being associated with

Y-RTS status. Alternatively, meeting
only 1 of the criteria reduced the posttest probability of being associated with
Y-RTS status compared to pretest probability (negative likelihood ratio, 0.16).
DISCUSSION
he purposes of this study were

(1) to examine differences in clinical variables (demographics, knee
impairments, and self-report measures)
between those who return to preinjury
level of sports participation and those
who do not at 1 year following ACL reconstruction, (2) to determine the factors
most strongly associated with return-tosport status in a multivariate model, and
(3) to explore the discriminatory value of
clinical variables associated with return
to sport at 1 year postsurgery. Although
the majority of patients in our study had
returned to sports following ACL reconstruction, only 55% reported they had
returned to preinjury levels of sports participation at 1 year. We hypothesized that
a combination of demographic, physical
impairment, and psychosocial measures
would differ and discriminate between
those who reported participation in
sports-related activities at preinjury levels and those who did not. This study
identified a variety of factors that differed
between groups based on return-to-sport
]
status, with knee impairment and self-reported function measures as the factors
most strongly associated with returning
to preinjury sports participation. These
factors are potentially modifiable and
should be considered when developing
return-to-sport rehabilitation guidelines
and participation criteria following ACL
reconstruction.
Many of the factors that differed between return-to-sport-status groups in
this study, such as quadriceps strength,
knee pain intensity, self-reported knee
function, and fear of movement/reinjury,
have also been associated with knee function in prior studies.11,19,30-32,45,58 The lack
of group differences in demographics indicates that nonmodifiable factors, such
as age, sex, and concomitant injury, or potentially modifiable factors, such as graft
type and time from injury to surgery, may
not play a significant role in return-tosport status. These findings support prior
studies that have failed to show a strong
relationship between demographic measures and function.5,16,18,25,28,35,39,44,47 An
interesting finding in this study was that
quadriceps peak torque on the surgical
side normalized to body weight differed
between return-to-sport-status groups,
but quadriceps symmetry index did not
differ between groups. Prior studies have
reported inconsistent results regarding
the influence of quadriceps performance
on functional outcomes.22,32,48,58 This inconsistency appears to be closely tied to
the method by which quadriceps performance is measured or the outcome
used22,32,48,58 and may be influenced by
variability in rehabilitation programs.
The results of this study indicate that
though quadriceps strength normalized
to body weight may be an important
consideration when determining ability
for return to sports, quadriceps strength
asymmetry is not a discriminating factor between return-to-sport groups. The
importance of quadriceps symmetry,
however, and its implication for reinjury
should not be overlooked. Prior studies
have demonstrated the predictive value
of strength asymmetries for risk of rein-
10/17/2012 2:58:38 PM

jury,43 and it is commonly suggested that

these asymmetries should be resolved
prior to initiation of sports activities.36,41,42
Although some variables previously
associated with function following ACL
reconstruction, such as knee pain intensity,32,58 fear of movement/reinjury,11,30-32
and quadriceps strength,32,45,58 had bivariate associations with return to preinjury sport participation, they were not
retained in multivariate analysis. Perhaps
the most unexpected finding was the exclusion of fear of movement/reinjury
from the model, because this has been
strongly associated with return to sports
participation in prior studies29,31 and was
the most prevalent reason cited for not
returning to sport in our sample. Some
authors have speculated that psychosocial factors, such as fear of movement/
reinjury, may help to explain the discrepancy between generally favorable knee
scores and poor return-to-sport rates
following surgery.2,3 It is plausible that
fear of movement/reinjury may mediate
the relationship between activity restrictions and factors included in the model
(ie, instability or self-reported function),
yet not be identified as a significant individual factor in multivariate analysis.
Thus, concurrent assessment of painrelated fear of movement/reinjury and
clinical measures may be unnecessary for
prediction of return-to-sport status, because no further variance was explained
by inclusion of this construct in the multivariate model.
A strength of this study is that it is
the first, to our knowledge, to study the
contributions of demographic, knee impairment, and psychosocial factors in a
multivariate analysis for the determination of return-to-sport status at 1 year
postsurgery. This is an important step
toward creating evidence to guide the
development of rehabilitation programs
and return-to-sport criteria to improve
outcomes following ACL reconstruction. There are several limitations of this
study to consider when interpreting the
results. This is a cross-sectional design;
therefore, it remains to be proven if the
variables identified in this study will longitudinally predict return-to-sport status

at 1 year postsurgery. One year is generally considered a short follow-up period
after ACL reconstruction; however, it has
been shown that, of those patients who
return to sports, most do so within the
first year.49 Furthermore, although most
patients were released to return to sport
at 6 months postsurgery, data on the timing of return to sport for each individual
patient were not collected or analyzed.
Therefore, some patients might have had
more or less time to be exposed to sport
activities than others, which should be
considered when interpreting the results.
The results of our study may not be
applied universally to all patients following ACL reconstruction. Patient status
as a coper or noncoper was not assessed,
and it is plausible that different factors
underlie functional recovery between
these groups.17,24 Our exclusion criteria
omitted those patients with concomitant
ligamentous and articular cartilage damage requiring surgical procedures. Furthermore, patients who did not return for
surgeon follow-up at 1 year postsurgery
were not tested. This inherent selection
bias should be considered when interpreting these results.
A final limitation of our study is the
use of a nonvalidated self-report measure of return to sports participation.
Most studies utilize self-report-of-function questionnaires that measure knee
performance across a wide spectrum of
constructs,11,31,32,45,48,58 and comparisons
are not often drawn between the ability to return to preinjury levels of sports
participation and the ability to return to
sports, even at a reduced level.54 Objective clinical comparison of preinjury to
postsurgery levels of sports participation
or performance also has its limitations
due to variable measurements of professional, amateur, and recreational athletic
performance across sports. Although our
methodology has not been validated, it
has the potential to provide a more accurate estimation of sport-related function
compared to preinjury levels.
Future studies should test the longitudinal validity of this model for prediction
of return-to-sport status, as well as examine other potentially important physical
performance measures, impairment variables, and psychological barriers related
to return to sport. This study only examined 1 psychosocial construct directly,
and it is possible that other psychosocial
factors may contribute more significantly
to function in multivariate models.15,60
One such factor, self-efficacy, has been
shown to be a preoperative predictor of
outcome 1 year after ACL reconstruction,53 and is predictive of improvements
in knee pain intensity and self-reported
function in the first 12 weeks following
surgery.12 Future studies should examine
the relationship of fear of movement/reinjury and other psychosocial constructs,
such as self-efficacy, longitudinally and
at follow-up times longer than 1 year to
determine which constructs best predict
return-to-sport status.
CONCLUSION
his study provides further insight into clinical variables that

empirically discriminate between
individuals in return-to-sport groups.
Results suggest that ongoing knee symptoms following ACL reconstruction are
associated with individuals returning
to preinjury sports participation levels.
These potentially modifiable factors represent important targets for rehabilitation. Findings from this study should be
considered in future longitudinal studies
aimed at the development of return-tosport rehabilitation guidelines and participation criteria. t
KEY POINTS
FINDINGS: Patients reporting return to
preinjury levels of sports participation had less knee joint effusion, fewer
episodes of knee instability, lower
knee pain intensity, higher quadriceps
peak torque-body weight ratio, higher
IKDC scores, and lower TSK-11 scores.
The strongest contributors to return-
10/17/2012 2:58:39 PM

[
to-sport status allocation were selfreported knee function (IKDC score),
frequency of knee instability, and knee
joint effusion.
IMPLICATIONS: Self-report and knee impairment variables differentiate those
who are able to return to preinjury
levels of sports participation from those
who are not at 1 year postsurgery, possibly identifying targets to address during
rehabilitation.
CAUTION: This study included only patients with primary ACL reconstruction,
without concomitant ligamentous or
articular cartilage damage requiring
repair. Thus, the results of our study
may not be applied universally to all
patients following ACL reconstruction.
The variables identified in this study
should be tested in longitudinal studies to determine their ability to predict
sport-related outcomes.
research report
7.
8.
9.
10.
11.
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685

Current Concepts Review

Operative Treatment of Primary Anterior

ACL reconstruction should be performed anatomically.

Anterior cruciate ligament (ACL) rupture is a common injury

J Bone Joint Surg Am. 2014;96:685-94

using the position of two osseous ridges on the medial wall of

Treatment of ACL Injuries

have been reported to occur in approximately 5% to 35% of

Bone-to-bone healing in both tunnels

Not suitable for double-bundle reconstruction

Comparable stiffness to native ACL

Risk of anterior kneeling pain

Invasive, large incision

Risk of patellar fracture

Weaker than native ACL

Graft size can be unpredictable

Minimal donor site morbidity

Comparable strength to native ACL

Not suitable for certain athletes who rely

Less stiffness than native ACL

Can be used for single or

Risk of patellar fracture

Option of a one-sided bone block

No donor site morbidity

Theoretical risk of disease transmission

Available in various types and sizes

Longer healing time

Increased risk of rerupture, especially in younger

bone-patellar tendon-bone graft is not suitable for double-bundle

surgeons and found a lack of agreement in the ideal position for

A standard 45 flexion weight-bearing posteroanterior (PA) radiograph,

of anatomic tunnel placement .

can be used to evaluate tunnel angle and implant position.

had ACL surgery. Therefore, nonoperative management may

Femoral and tibial three-dimensional CT reconstructions demonstrating

single-bundle reconstruction. The only significant difference in

Femoral and tibial three-dimensional CT reconstructions demonstrating

the available evidence to support augmentation was weak but

TABLE II Grades of Recommendation for Operative Treatment of

*Grade A indicates good evidence (Level-I studies with consistent

that the rate of osteoarthritis was 2% and 8%, respectively, beyond

including early recognition via advanced imaging modalities or

46. Rappe M, Horodyski M, Meister K, Indelicato PA. Nonirradiated versus irradiated

69. Georgoulis AD, Papadonikolakis A, Papageorgiou CD, Mitsou A, Stergiou N.

Journal of Orthopaedic & Sports Physical Therapy

Return to Preinjury Sports Participation

TTOBJECTIVES: (1) To examine differences in

TTBACKGROUND: Demographic, physical impair-

ment, and psychosocial factors individually prohibit

TTMETHODS: Ninety-four patients (60 men; mean

acteristic curves determined the discriminatory

TTRESULTS: Fifty-two of 94 patients (55%) report-

ed yes return to sports. Patients reporting return to

TTCONCLUSION: In multivariate analysis, the fac-

tors most strongly associated with return-to-sport

TTLEVEL OF EVIDENCE: Prognosis, level 2b.

J Orthop Sports Phys Ther 2012;42(11):893-901,

TTKEY WORDS: ACL, kinesiophobia, return to

nterior cruciate ligament

42-11 Lentz.indd 893

Journal of Orthopaedic & Sports Physical Therapy

onsecutive patients with ACL