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There Is Substantial Variation in Rehabilitation Protocols Following Anterior Cruciate Ligament Reconstruction: A Survey of 46 American Orthopaedic Surgeons

      Purpose

      To identify the clinical practice preferences of orthopaedic surgeons regarding anterior cruciate ligament reconstruction (ACLR) rehabilitation through a survey of members of the Arthroscopy Association of North American (AANA) and the American Orthopaedic Society for Sports Medicine (AOSSM).

      Methods

      An online survey was distributed to members of AANA and AOSSM between November 2020 and September 2021. Participants reported on their clinical preferences for ACLR protocol development and patient selection, use of technology in ACLR recovery and rehabilitation, and preferences for advancing through multiple phases of the rehabilitative process.

      Results

      Responses from 46 orthopaedic surgeons were analyzed. Patient-reported outcome measures were not found to be utilized often at various phases of the perioperative period. Thirty-eight (82.6%) participants reported utilization of postoperative bracing. There was no consensus on when participants allow their patients to advance through rehabilitation, but most report waiting 3 to 4 months for advancement to jogging/lateral movement, 6 to 8 months for return to noncontact sport, and 9 months of more for return to unrestricted sport. Many participants utilize functional and strength testing with associated limb symmetry indices to determine patient readiness to return to sport, with 18, 26, and 25 participants reporting use of functional testing and 28, 26, and 27 participants reporting use of strength testing at the return to jogging/lateral movements, noncontact return to sport, and unrestricted return-to-sport phases, respectively.

      Conclusions

      This study provides an insight into the rehabilitative protocols and modalities utilized for ACLR by orthopaedic surgeons in practice across the United States. There is notably substantial variation in rehabilitative patterns and preferences, particularly with regards to what constitutes criteria for progressing patients through the phases of returning to unrestricted sport. Additionally, our findings show that while many surgeons believe that quantitative assessment technology could be beneficial in decision-making for returning patients to sport, there are still many barriers that stand in the way of its implementation into clinical practice.

      Clinical Relevance

      Postoperative rehabilitative protocols after ACLR vary by surgeon.
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      References

        • Csintalan R.P.
        • Inacio M.C.S.
        • Funahashi T.T.
        Incidence rate of anterior cruciate ligament reconstructions.
        Perm J. 2008; 12: 17-21
        • Ardern C.L.
        • Webster K.E.
        • Taylor N.F.
        • Feller J.A.
        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: 596-606https://doi.org/10.1136/bjsm.2010.076364
        • Greenberg E.M.
        • Greenberg E.T.
        • Albaugh J.
        • Storey E.
        • Ganley T.J.
        Rehabilitation practice patterns following anterior cruciate ligament reconstruction: A survey of physical therapists.
        J Orthop Sports Phys Ther. 2018; 48: 801-811https://doi.org/10.2519/jospt.2018.8264
        • Greenberg E.M.
        • Greenberg E.T.
        • Albaugh J.
        • Storey E.
        • Ganley T.J.
        Anterior cruciate ligament reconstruction rehabilitation clinical practice patterns: A survey of the PRiSM Society.
        Orthop J Sports Med. 2019; 7232596711983904https://doi.org/10.1177/2325967119839041
        • Ajuied A.
        • Smith C.
        • Wong F.
        • Hoskinson S.
        • Back D.
        • Davies A.
        A survey of rehabilitation regimens following isolated ACL reconstruction.
        JMED Res. 2014; 2014118077
        • Grassi A.
        • Vascellari A.
        • Combi A.
        • Tomaello L.
        • Canata G.L.
        • Zaffagnini S.
        Return to sport after ACL reconstruction: A survey between the Italian Society of Knee, Arthroscopy, Sport, Cartilage and Orthopaedic Technologies (SIGASCOT) members.
        Eur J Orthop Surg Traumatol. 2016; 26: 509-516https://doi.org/10.1007/s00590-016-1756-0
        • Carter H.M.
        • Littlewood C.
        • Webster K.E.
        • Smith B.E.
        The effectiveness of preoperative rehabilitation programmes on postoperative outcomes following anterior cruciate ligament (ACL) reconstruction: A systematic review.
        BMC Musculoskelet Disord. 2020; 21: 647https://doi.org/10.1186/s12891-020-03676-6
        • Failla M.J.
        • Logerstedt D.S.
        • Grindem H.
        • et al.
        Does extended preoperative rehabilitation influence outcomes 2 years after ACL reconstruction? A comparative effectiveness study between the MOON and Delaware-Oslo ACL cohorts.
        Am J Sports Med. 2016; 44: 2608-2614https://doi.org/10.1177/0363546516652594
        • O’Malley E.
        • Richter C.
        • King E.
        • et al.
        Countermovement jump and isokinetic dynamometry as measures of rehabilitation status after anterior cruciate ligament reconstruction.
        J Athl Train. 2018; 53: 687-695https://doi.org/10.4085/1062-6050-480-16
        • Eysenbach G.
        Improving the quality of web surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES).
        J Med Internet Res. 2004; 6: e34https://doi.org/10.2196/jmir.6.3.e34
        • Wiertsema S.H.
        • van Hooff H.J.A.
        • Migchelsen L.a.A.
        • Steultjens M.P.M.
        Reliability of the KT1000 arthrometer and the Lachman test in patients with an ACL rupture.
        Knee. 2008; 15: 107-110https://doi.org/10.1016/j.knee.2008.01.003
        • Ayeni O.R.
        • Chahal M.
        • Tran M.N.
        • Sprague S.
        Pivot shift as an outcome measure for ACL reconstruction: A systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 767-777https://doi.org/10.1007/s00167-011-1860-y
        • Van Dyck P.
        • Vanhoenacker F.M.
        • Lambrecht V.
        • et al.
        Prospective comparison of 1.5 and 3.0-T MRI for evaluating the knee menisci and ACL.
        J Bone Joint Surg Am. 2013; 95: 916-924https://doi.org/10.2106/JBJS.L.01195
        • Kaeding C.C.
        • Léger-St-Jean B.
        • Magnussen R.A.
        Epidemiology and diagnosis of anterior cruciate ligament injuries.
        Clin Sports Med. 2017; 36: 1-8https://doi.org/10.1016/j.csm.2016.08.001
        • Ezzat A.M.
        • Whittaker J.L.
        • Brussoni M.
        • Mâsse L.C.
        • Emery C.A.
        The English Knee Self-Efficacy Scale is a valid and reliable measure for knee-specific self-efficacy in individuals with a sport-related knee injury in the past 5 years.
        Knee Surg Sports Traumatol Arthrosc. 2021; 29: 616-626https://doi.org/10.1007/s00167-020-05974-x
        • Darnall B.D.
        • Sturgeon J.A.
        • Cook K.F.
        • et al.
        Development and validation of a daily pain catastrophizing scale.
        J Pain. 2017; 18: 1139-1149https://doi.org/10.1016/j.jpain.2017.05.003
        • Briggs K.K.
        • Lysholm J.
        • Tegner Y.
        • Rodkey W.G.
        • Kocher M.S.
        • Steadman J.R.
        The reliability, validity, and responsiveness of the Lysholm score and Tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later.
        Am J Sports Med. 2009; 37: 890-897https://doi.org/10.1177/0363546508330143
        • Risberg M.A.
        • Holm I.
        • Steen H.
        • Beynnon B.D.
        Sensitivity to changes over time for the IKDC form, the Lysholm score, and the Cincinnati knee score: A prospective study of 120 ACL reconstructed patients with a 2-year follow-up.
        Knee Surg Sports Traumatol Arthrosc. 1999; 7: 152-159https://doi.org/10.1007/s001670050140
        • Marx R.G.
        • Stump T.J.
        • Jones E.C.
        • Wickiewicz T.L.
        • Warren R.F.
        Development and evaluation of an activity rating scale for disorders of the knee.
        Am J Sports Med. 2001; 29: 213-218https://doi.org/10.1177/03635465010290021601
        • Horn M.E.
        • Reinke E.K.
        • Couce L.J.
        • Reeve B.B.
        • Ledbetter L.
        • George S.Z.
        Reporting and utilization of Patient-Reported Outcomes Measurement Information System® (PROMIS®) measures in orthopedic research and practice: a systematic review.
        J Orthop Surg Res. 2020; 15: 553https://doi.org/10.1186/s13018-020-02068-9
        • Irrgang J.J.
        • Snyder-Mackler L.
        • Wainner R.S.
        • Fu F.H.
        • Harner C.D.
        Development of a patient-reported measure of function of the knee.
        J Bone Joint Surg Am. 1998; 80: 1132-1145https://doi.org/10.2106/00004623-199808000-00006
        • Sadeqi M.
        • Klouche S.
        • Bohu Y.
        • Herman S.
        • Lefevre N.
        • Gerometta A.
        Progression of the psychological ACL-RSI score and return to sport after anterior cruciate ligament reconstruction: A prospective 2-year follow-up study from the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST).
        Orthop J Sports Med. 2018; 62325967118812819https://doi.org/10.1177/2325967118812819
        • Laboute E.
        • Savalli L.
        • Puig P.L.
        • Trouve P.
        • Larbaigt M.
        • Raffestin M.
        Validity and reproducibility of the PPLP scoring scale in the follow-up of athletes after anterior cruciate ligament reconstruction.
        Ann Phys Rehabil Med. 2010; 53: 162-179https://doi.org/10.1016/j.rehab.2010.01.004
        • Alcock G.K.
        • Werstine M.S.
        • Robbins S.M.
        • Stratford P.W.
        Longitudinal changes in the lower extremity functional scale after anterior cruciate ligament reconstructive surgery.
        Clin J Sport Med. 2012; 22: 234-239https://doi.org/10.1097/JSM.0b013e31824cb53d
        • Wellsandt E.
        • Failla M.J.
        • Snyder-Mackler L.
        Limb symmetry indexes can overestimate knee function after anterior cruciate ligament injury.
        J Orthop Sports Phys Ther. 2017; 47: 334-338https://doi.org/10.2519/jospt.2017.7285
        • Davies W.T.
        • Myer G.D.
        • Read P.J.
        Is it time we better understood the tests we are using for return to sport decision making following ACL reconstruction? A critical review of the hop tests.
        Sports Med. 2020; 50: 485-495https://doi.org/10.1007/s40279-019-01221-7
        • Kim J.S.
        • Hwang U.J.
        • Choi M.Y.
        • et al.
        Correlation between Y-balance test and balance, functional performance, and outcome measures in patients following ACL reconstruction.
        Int J Sports Phys Ther. 2022; 17: 193-200https://doi.org/10.26603/001c.31873
        • Glattke K.E.
        • Tummala S.V.
        • Chhabra A.
        Anterior cruciate ligament reconstruction recovery and rehabilitation: A systematic review.
        J Bone Joint Surg Am. 2022; 104: 739-754https://doi.org/10.2106/JBJS.21.00688
        • Davidson K.W.
        • Shaffer J.A.
        • Ye S.
        • et al.
        Interventions to improve hospital patient satisfaction with healthcare providers and systems: A systematic review.
        BMJ Qual Saf. 2017; 26: 596-606https://doi.org/10.1136/bmjqs-2015-004758
        • Paterno M.V.
        • Flynn K.
        • Thomas S.
        • Schmitt L.C.
        Self-reported fear predicts functional performance and second ACL injury after ACL reconstruction and return to sport: A pilot study.
        Sports Health. 2018; 10: 228-233https://doi.org/10.1177/1941738117745806
        • Badawy C.R.
        • Jan K.
        • Beck E.C.
        • et al.
        Contemporary principles for postoperative rehabilitation and return to sport for athletes undergoing anterior cruciate ligament reconstruction.
        Arthrosc Sports Med Rehabil. 2022; 4: e103-e113https://doi.org/10.1016/j.asmr.2021.11.002
        • Cole B.J.
        • Cotter E.J.
        • Wang K.C.
        • Davey A.
        Patient understanding, expectations, outcomes, and satisfaction regarding anterior cruciate ligament injuries and surgical management.
        Arthroscopy. 2017; 33: 1092-1096https://doi.org/10.1016/j.arthro.2017.01.049
        • Renna M.S.
        • Metcalfe A.
        • Ellard D.
        • Davies D.
        A patient satisfaction survey investigating pre- and post-operative information provision in lower limb surgery.
        BMC Musculoskelet Disord. 2020; 21: 754https://doi.org/10.1186/s12891-020-03761-w
        • Lindström M.
        • Wredmark T.
        • Wretling M.L.
        • Henriksson M.
        • Felländer-Tsai L.
        Post-operative bracing after ACL reconstruction has no effect on knee joint effusion: A prospective, randomized study.
        Knee. 2015; 22: 559-564https://doi.org/10.1016/j.knee.2015.04.015
        • Taradaj J.
        • Halski T.
        • Kucharzewski M.
        • et al.
        The effect of neuromuscular electrical stimulation on quadriceps strength and knee function in professional soccer players: Return to sport after ACL reconstruction.
        Biomed Res Int. 2013; 2013802534https://doi.org/10.1155/2013/802534
        • Hauger A.V.
        • Reiman M.P.
        • Bjordal J.M.
        • Sheets C.
        • Ledbetter L.
        • Goode A.P.
        Neuromuscular electrical stimulation is effective in strengthening the quadriceps muscle after anterior cruciate ligament surgery.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 399-410https://doi.org/10.1007/s00167-017-4669-5
        • Toth M.J.
        • Tourville T.W.
        • Voigt T.B.
        • et al.
        Utility of neuromuscular electrical stimulation to preserve quadriceps muscle fiber size and contractility after anterior cruciate ligament injuries and reconstruction: A randomized, sham-controlled, blinded trial.
        Am J Sports Med. 2020; 48: 2429-2437https://doi.org/10.1177/0363546520933622
        • Fu C.L.
        • Yung S.H.
        • Law K.Y.
        • et al.
        The effect of early whole-body vibration therapy on neuromuscular control after anterior cruciate ligament reconstruction: A randomized controlled trial.
        Am J Sports Med. 2013; 41: 804-814https://doi.org/10.1177/0363546513476473
        • Maghbouli N.
        • Khodadost M.
        • Pourhassan S.
        The effectiveness of vibration therapy for muscle peak torque and postural control in individuals with anterior cruciate ligament reconstruction: A systematic review and meta-analysis of clinical trials.
        J Orthop Traumatol. 2021; 22: 28https://doi.org/10.1186/s10195-021-00589-5
        • Beischer S.
        • Gustavsson L.
        • Senorski E.H.
        • et al.
        Young athletes who return to sport before 9 months after anterior cruciate ligament reconstruction have a rate of new injury 7 times that of those who delay return.
        J Orthop Sports Phys Ther. 2020; 50: 83-90https://doi.org/10.2519/jospt.2020.9071
        • Grindem H.
        • Snyder-Mackler L.
        • Moksnes H.
        • Engebretsen L.
        • Risberg M.A.
        Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: The Delaware-Oslo ACL cohort study.
        Br J Sports Med. 2016; 50: 804-808https://doi.org/10.1136/bjsports-2016-096031
        • Gokeler A.
        • Dingenen B.
        • Hewett T.E.
        Rehabilitation and return to sport testing after anterior cruciate ligament reconstruction: Where are we in 2022?.
        Arthrosc Sports Med Rehabil. 2022; 4: e77-e82https://doi.org/10.1016/j.asmr.2021.10.025
        • Thomeé R.
        • Neeter C.
        • Gustavsson A.
        • et al.
        Variability in leg muscle power and hop performance after anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1143-1151https://doi.org/10.1007/s00167-012-1912-y
        • Webster K.E.
        • McPherson A.L.
        • Hewett T.E.
        • Feller J.A.
        Factors associated with a return to preinjury level of sport performance after anterior cruciate ligament reconstruction surgery.
        Am J Sports Med. 2019; 47: 2557-2562https://doi.org/10.1177/0363546519865537