Upload
others
View
8
Download
0
Embed Size (px)
Citation preview
BRYAN CLARY, PABLO ALVAREZ, DAN HANSON, ANDY GEAN
Athletic ACL Injury Management
- Prehab
- Rehab
- Performance
- Prevention
Center for Sports Medicine and Orthopaedics
22 Physicians
9 Physician Assistants
2 Nurse Practitioners
42 Physical and Occupational Therapists
11 Athletic Trainers
375 total employees
10 Locations
Incidence and Impact of Injury
Growing Prevalence
1994 – 86,687
2013 – 148,714
$32,00-$50,000
Female Risk
2.3 – 9.7x higher incidence rate
Why Female?
Not Anthropometric
No increase in hip width
No correlation to notch width
Ligament Dominance
Quad Dominance
Leg Dominance
Sport Specialization? (DiCesare, 2019)
ACL Anatomy
Restricts anterior translation of
tibia on femur and extreme
tibial rotation
2 bundles
Anteromedial
Hyperextension
Full Flexion
Posterolateral
Hyperextension
Bundle strain vary
http://www.orthonet.pitt.edu/content/DoubleBundle.htm
Pathomechanics of Rupture
Non- Contact Knee valgus/internal tibial rotation on
relatively straight knee
Cutting, Single-leg landing, deceleration
Contact Hyperextension or valgus external
forces http://maxpotentialsports.files.wordpress.com/2013/06/acl-tear_valgus1.png
40 ms
70% N
on
–C
on
ta
ct I
nju
ry
Dynamic Q-Angle
Proximally
Femoral Adduction
Femoral IR
Distally
Pronation
Tibial internal Rotation
Associated Injuries
Ligament
Injuries
Articular
Cartilage
Injury
Bone
Bruise
Capsular
Injury
Meniscal
Injury
15% - 40% incidence with acute ACL
Higher rate of osteoarthritis
100% with meniscectomy
50% without meniscectomy (Jomha NM, 1999)
No convincing evidence that arthrosis can be
prevented by ACL reconstruction
Articular Cartilage
Injury
80% of ACL injuries have lateral compartment bone bruise
Hopeful resolvement by 6 months
Articular cartilage thinning possible
No correlation with pain level (Boks, 2007)
MCL reconstruction not advocated
Minimal separation = usually heals adequately Ligament
Injuries
Posterolateral corner injuries rare with ACL injury
Preoperative considerations
Standard is to achieve “quiet knee” (AJSM 2016)
Full ROM (Heijne)
No Pain
Quad Activation
Minimal Effusion
Bone bruise on the Lateral Femoral Condyle only predictor of delay in full extension (Gage 2019)
When to operate?
18 days (AJSM 1991)
3 weeks (AJSM 1992)
28 days (OJSM 2018)
“Prehab”
Phase 1 – Achieve quiet knee
Phase 2 – Restore muscle strength and neuromuscular
response
• Compared the patients of the Delaware-Oslo ACL Cohort to the MOON Cohort
• Athletes who underwent vigorous prehabilitationreturned to preinjury sport significantly higher (72%) than those in MOON, who did not. (63%)
Allograft vs Autograft - Stability
Sun et al. 2009.
86 BPTB autograph vs 86 BPTB allograft
Average follow up 5.6 years
No difference in stability found in Lachman test, pivot-shift, mean laxity with arthometer testing, or percentage of knees >3mm laxity
Most studies low level secondary to allograft sterilization techniques
45% rupture rate at 6 years with gamma irradiation (Gorschewsky et al, 2005)
Relatively equivalent stability
Autograft Stability – BPTB vs HS vs QT
Meta-Analysis of 6 RCT’s comparing HT vs BPTB at 2 years = No statistical difference in Lachman’s
BPTB – significantly decreased risk of positive pivot-shift
Spindler et al, 2004. Systematic review of 7 RCT’s
3 showed increased laxity with HS
2 of 3 used 2 strand HS graft
4 showed no difference
No significant difference between QT vs BPTB
Failure Rate – Allograft vs. Autograft
Kaeding et al. 2011.
allograft and younger age found to significantly increase risk of graft failure in first 2 years
7% more safe per year (Maletis et al, 2013)
Foster et al. 2010.
IKDC similar between allograft vs autograft
Allograft 8.2 per 100 failure vs 4.7 per 100 failure Autograft
Maletis, et al. 2013
9817 patients
Revision rates BPTB (1.18%) vs HS (1.56%) vs Allograft (1.74%)
98% vs 96.9% vs 96% survival at 2.7 years
What Graft for a 20 y/o Division 1 or NFL running back?
Criteria for running back return to play?
How long until return to play for running back?
Single bundle or double bundle for running back?
Knee brace?
What Graft for 25 y/o recreational athlete?
What Graft for 35 y/o recreational athlete?
(Erickson et al. 2014)
Running back?
86.1% BPTB.
99.3% autograft only
25 y/o recreational athlete?
49% BPTB
43% 4-strand HS
35 y/o recreational athlete?
45% 4-strand HS
What criteria for return to sport?
74.5% passed return to play testing
56.9% also require normal
ROM/pain/strength
Single vs Double?
99.3% Single
Brace?
64% say No
References
Beynnon, B. D. "Treatment Of Anterior Cruciate Ligament Injuries, Part I". American Journal of Sports Medicine 33.10 (2005): 1579-
1602. Web.
Wilk, K. (2015). Anterior Cruciate Ligament Injury Prevention and Rehabilitation: Let's Get It Right. Journal of Orthopaedic &
Sports Physical Therapy, 45(10), pp.729-730.
DiCesare, C., Montalvo, A., Barber Foss, K., Thomas, S., Ford, K., Hewett, T., Jayanthi, N., Stracciolini, A., Bell, D. and Myer, G. (2019). Lower Extremity Biomechanics Are Altered Across Maturation in Sport-Specialized Female Adolescent Athletes. Frontiers
in Pediatrics, 7.
Failla, M., Logerstedt, D., Grindem, H., Axe, M., Risberg, M., Engebretsen, L., Huston, L., Spindler, K. and Snyder-Mackler, L. (2016). Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?. The American Journal of
Sports Medicine, 44(10), pp.2608-2614.
Heijne A, Ang BO, Werner S. Predictive factors for 12-month outcome after anterior cruciate ligament reconstruction. Scand J
Med Sci Sports. 2009;19(6):842-849.
Gage, A., Kluczynski, M., Bisson, L. and Marzo, J. (2019). Factors Associated With a Delay in Achieving Full Knee Extension Before Anterior Cruciate Ligament Reconstruction. Orthopaedic Journal of Sports Medicine, 7(3), p.232596711982954.
Shelbourne KD, Wilckens JH, Mollabashy A, DeCarlo M. Arthrofibrosis in acute anterior cruciate ligament reconstruction: the
effect of timing of reconstruction and rehabilitation. Am J Sports Med. 1991; 19(4):332-336.
Harner CD, Irrgang JJ, Paul J, Dearwater S, Fu FH. Loss of motion after anterior cruciate ligament reconstruction. Am J Sports
Med. 1992;20(5):499-506.
References
Huleatt J, Gottschalk M, Fraser K, et al. Risk factors for manipulation under anesthesia and/or lysis of adhesions after anterior cruciate ligament reconstruction. Orthop J Sports Med. 2018;6(9): 2325967118794490.
Eitzen, I., Moksnes, H., Snyder-Mackler, L. and Risberg, M. (2010). A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury. Journal of Orthopaedic & Sports Physical Therapy, 40(11), pp.705-721.
Kaeding C, Aros B, Pedroza A, et al. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health. 2011;3(1):9.
Foster TE, Wolfe BL, Ryan S, Silvestri L, Kaye EK. Does the graft source really matter in the outcome of patients undergoing anterior cruciate ligament reconstruction? An evaluation of autograft versus allograft reconstruction results: A systematic review. Am J Sports Med 2010
Maletis GB, Inacio MC, Desmond JL, Funahashi TT. Reconstruction of the anterior cruciate ligament: association of graft choice with increased risk of early revision. Bone Joint J 2013; 95-B: 623-628 [PMID: 23632671 DOI: 10.1302/0301-620 X.95B5.30872
Sun K, Tian SQ, Zhang JH, Xia CS, Zhang CL, Yu TB. Anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft versus allograft. Arthroscopy. 2009;25(7):750-759.
Spindler KP, Kuhn JE, Freedman KB, Matthews CE, Dittus RS, Harrell FE Jr. Anterior cruciate ligament reconstruction autograft choice: bone-tendonbone versus hamstring: does it really matter? A systematic review. Am J Sports Med. 2004;32(8):1986-1995.
BEYOND PROTOCOLS
PABLO ALVAREZ, PT, MSPT
ACL REHABILITATION
FOR THE ATHLETE
OBJECTIVES
•Whole Body Approach
•Minimizing Compensations
•Cardiovascular Demands
•Dynamic Readiness
•Nutrition
•Psychological Implications
•Restoring Strength
Whole Body Approach
Clear joint above and below…….but
then what?
Core/Trunk Control
TS and UE
Mobility and Flexibility
Cardiovascular Demands
Increase Blood Flow
Caloric Demands
Maintain Conditioning
TUNNEL VISION
Minimize Compensations
• How do you identify Compensations?
• Easy to hide for Athletes
• FMS/SFMA
• Do you know how to evaluate and
correct a Squat?
• Coach every repetition!!!
Dynamic Readiness
What does it
mean to by
Dynamic?
Early
Introduction
Hand eye
coordination
Nutritional Considerations
Eating for Rehab
Cleveland Clinic – Our bodies need more calories, protein, vitamins to promote healing
Foods that control Inflammation
Pre and Post Therapy Nutrition
Weight Control
Both losing and gaining weight can be a problem
Hydration
MUST “Have The Talk”
Coordinate with a Nutritionist /Dietician
Psychological Considerations
Negative Consequences
of dealing with an Injury
• Anxiety
• Stress
• Depression
Intervention Techniques
▪ Effective Communication
▪ Goal Setting
▪ Relaxation and Breathing Techniques
▪ Motivation
▪ Create a positive environment for your athletes
Restoring Strength
Early quad activation
Early Extension Vital
OCK vs CKC
JOSPT (2018)
Flemming et al. 2005
BFR
Sudo et al. 2017
BFR induces muscle fiber hypertrophy
Slysz et al. 2016
Low Load w/ BFR = exaggerated response
Restoring Strength
Periodization
Appropriate Progression
3 Sets of 10…….WHY???
Strength vs Power vs Hypertrophy
Therapy Done…Now What?
Transition to Performance Training
References
Sudo, M., Ando, S., & Kano, Y. (2017) Repeated BFR induces muscle fiber hypertrophy. Muscle Nerve, 55(2) 274-276
Slysz, J., Stultz, J. & Burr, J.F. (2016). The efficacy of blood flow restricted exercise: A systematic review & meta-analysis. J Sci Med Sport 19(8), 669-675
Keylock, K., Young, H. (2010). Delayed would healing: Can exercise accelerate it? Int J Exercise Science. 2010; 3(3): 70-78
Craft, LL., Perna, F., The benefits of exercise of the clinically depressed. Prim Companion J Clin Psychiatry. 2004;6(3): 104-11
https://my.clevelandclinic.org/health/articles/11111-nutrition-guidelines-to-improve-wound-healing
FLEMING, B.C., H. OKSENDAHL, and B.D. BEYNNON. Open- or closed-kinetic chain exercises after anterior cruciate ligament reconstruction? Exerc. Sport Sci. Rev., Vol. 33, No. 3, pp. 134–140, 2005.
THANK YOU!
CSCS, USAW-L1
SPORTS PERFORMANCE COACH
Dan Hanson
Fundamentals of Strength Training
Strength ≠ Hypertrophy
- Work Capacity (early)
- High repetition (15-20)
- Metabolic conditioning : can be integrated w/ deceleration +
linear speed training
- Deceleration/landing exercises are relatively low intensity + higher
volume
Strength Phase
- :Phasic Potentiation
- : heavy compound lifts (trap bar deadlift/BB Squat)
*heavy is relative!
- : 3-8 reps/3-5 sets per exercise (*don’t live in 3x10)
- : complimented with unilateral eccentric accessories (maintaining
secondary/retaining load – hypertrophy)
- : more aggressive deceleration/landing exercises with lower
volume
Strength Training Post-Rehab
“While squat progressions are well known (yet
amazingly still under-utilized), very few protocols
incorporate deadlifts and if they do, it is often in a
single-leg platform with a balance emphasis.
Additionally, hamstring weakness when matched
to their male counterparts, as opposed to
quadriceps weakness, may be a bigger predictor
for ACL injury and subsequent re-injury in females
(G.D. Myer, 2009).”
Strength Training Post-Rehab (cont.)
“The deadlift (and barbell squat)
addresses core strength to a greater
extent than conventional “core”
exercises (Hamlyn N, 2007).”
Speed (linear vs. COD)
Deceleration = Eccentric Quad Strength + Isometric Post. Chain
Strength
Bilateral Deceleration + Unilateral Deceleration (w/ support)
1) Linear Speed (straight line – Jog vs Run vs Walk)
2) Lateral Linear Speed (shuffling and/or running straight line)
3) Linear COD (sprint/shuffle/backpedal straight line)
4) Multi-Directional COD
Closed → Open
Closed → Open : Change of Direction
“Closed” Directional Movement
- used early in training process
- ex: T-Drill, Pro Agility (5-10-5), Square Drill
“Open” Directional Movement
- advanced drills in training process
- variety of coaches cues
: verbal (clap/whistle/”go!”)
: visual (point/ball toss/partner reaction)
Jumping/Landing
Lots of small landing success early on (fwd, bilateral)
Creating Force vs Absorbing Force
Mio Jumps – “Short and successful!”
Later expand to different directions
: Bilateral Landing + Rotation, Bilateral Broad Jump
: Unilateral Skater, Unilateral 45 deg Skater
: Advanced Stages – add perturbation
*these can be done with limited space and little to no
equipment
“what I need to see to feel good
about you returning to sport”
Linear Speed (can you sprint?)
Deceleration (can you decelerate from a full sprint?)
Open COD (can you change direction with an open cue?)
ROM (can you squat full ROM? *excluding other limiting factors)
Core Stability (Horizontal Trunk Hold/Elbow Plank *strength vs endurance)
RTS – “Assessments should be
descriptive, not predictive.”
90%??
Unilateral Jump/Land
“Eye Test”
What are the demands of sport? The ultimate goal of
performance training is to prepare the athlete for the
demands of sport.
ANDY GEAN, PT, DPT, OCS, COMT
Evidence for
Return to Sport
Decision-Making
The Question
One of the most complex questions in
sports medicine
When?
Based on what criteria?
Relevant factors?
Level of “readiness”?
Inherent risks?
When can I play
again?
Athlete
Parent
CoachATC
Parent
When Athletes Do Return…
Clin J Sports Med 2012
63 patients < 25 y.o.
25.4% risk of susequent ACL Injury within 12 mos of RTS
15x greater risk than controls
Females:
4x greater ipslilat, 6x greater contralat injury likelihood than males
Am J Sports Med 2016
242 patients <18 y.o.
31% risk for subsequent injury
2nd Injury
First 12 months post-ACLR: 50% of graft ruptures occur during this time
Age < 20: Graft rupture and contralat injury more common
BJSM 2014
Meta-Analysis 7556 individuals, 69 studies
81% returned to any sport
65% returned to pre-injury level of sport
55% returned to pre-injury competitive level (production/performance)
Return to Sport
Factors Age
Gender (?)
Sport
Competitive Level
Timing of season
Psychological readiness
External factors
Concomitant Procedure
Minimal Criteria
Full joint motion
No swelling
Joint stability
KT-1000
<3 mm side to side difference
Return to Sport:
Progressive, multi-level continuum of
assessment
The Return-to-Sport Question:
What objective, qualitative data do I need to consider in assisting with the RTS decision?
Does objective data aid in making an informed decision?
A Proposed RTS Checklist
Hewett & Webster CJSM 2017
Kinesthesia, Balance, Proprioception
Movement Biomechanics
Laxity, Graft, Bone Bruise, Anthropometrics
Strength, Power, (and Fatigue?)
Psychological Factors and Demographics
CSMO ACL RTS Checklist:• FMS, YBT: 12 weeks
• Strength Testing: 4+
months
• Hop Testing: 5+ months
• Normalization of jump,
landing biomechanics
• Field Tests• OFR→RTT→RTC→RTP
Kinesthesia, Balance, Propropception• Y Balance Test (Star Excursion Balance
Test)
• Objective, single leg motor control
• “Functional goniometer”
• Thresholds:• Anterior (<4 cm difference)
• Posterior medial (<6 cm)
• Posterior lateral (<6cm)
• Composite: >90-95% relative to limb
length
• Performance on YBT at 12 wks post-ACLR
correlated with passing hop tests at 6
mos• Garrison et al. IJSPT
• Statistically significant relationship
between anterior reach and knee
extensor deficits• Myers et al. IJSPT
Strength
Post-op deficits: debilitating, ubiquitous
Strength: Must quantify and normalize
90% of contralateral (or greater)
Knee flexors and extensors
Deficits vary by graft
Extensors: quad, BPTB grafts
Flexors: HS graft
Goals:
Minimize extensor deficits
Females: Commonly “quad dominant” →Restore Q:HS ratio
Objective Strength Measures:
Isokinetic
Peak flexor, extensor force at 60, 120, 180 deg/s
Quad:HS ratio
Peak torque:Body weight
Hand Held Dynamometry
Rep Max: 1 RM, 10 RM
Commonly assessed at 3 (?), 6, 9, 12+ months
Restory Limb Symmetry
Many movements remain asymmetric, abnormal several months post-ACLR
LSI commonly utilized post ACLR
Strength
Hop tests
Double limb squat
Video, pressure sensor mat (ex. Boditrak): L/R symmetry
Single limb squat
Quality reps to fatigue
Double limb vertical jump
Video, pressure sensor mat (Boditrak): L/R take off, landing symmetry
Single limb vertical jump
Jump mat L vs R
App
Single limb hop test
Single hop for distance, triple hop for distance, triple crossover
Restoring Limb Symmetry: Hop Tests
Most Researched
Single limb hop test
Single
Triple
Triple-cross
6 m time
Variations
Less researched
Timed lateral hop: 30 sec, two lines 40 cm apart, record number of side to side hops
Medial rotation hop: 90 deg medial rot→hop for distance
Restoring Limb
Symmetry: Hop
Tests
Single limb hop test
Single
Triple
Triple-cross
Timed lateral hop
Medial rotation hop:
Movement Quality
Body weight x 1: Functional
Movement Screen
Screen - NOT Predictive
Identify dysfunctional and/or painful
movements
7 Fundamental movement patterns
Double and single limb
Upper extremity
Core
Symmetric and asymmetric patterns
Jump/Landing Tasks:
Paterno et al: Landing mechanics
associated w/ 2nd injury
Assessment: Double, single leg
landing/jumps
Ground Reaction Force: 2-6x BW
Most accurately measured on force
plates
Video analysis correlates with force
plate measures
Clinical Tool: Landing Error Scoring
System (LESS)
Functional Movement Screen
4.7x greater injury rate if score <17
Letafatkar IJSPT 2014
Female collegiate athletes: 4x greater chance of LE injury if score < 14
SN:0 0.58, SP: 0.74
Chorba NAJSPT 2010
Professional Football: Score of <15 →Associated with serious LE injury
SN: 0.54, SP: 0.91
Kiesel NAJSPT 2007
LESS (Landing Error Scoring System)
Clinical Tool: Landing
Error Scoring System
Double leg drop
jump
Video assessment
19 Items scored: 0
(Good), 1
(Deduction)
Lower risk: <5, Higher
risk: >5
Landing Mechanics & 2nd Injury
Variables Predictive of 2nd
injury:
Net Hip IR (dynamic valgus)
moment at landing
Unequal sagittal (L/R) knee
moment at landing
2-D frontal plane (valgus)
knee excursion
56 female athletes: 13 2nd
ACL injury with 1 year
SN: 0.92, SP: 0.88
RTS Batteries
• Do RTS batteries have clinical utility?
• Hewett & Webster Sports Med2019
• Meta-Analysis • Passing RTS criteria reduced risk
graft rupture by 60%• Only 23% passed RTS criteria
• Increased the risk of contralateral ACL rupture by 235%
• Questionable Inclusion Criteria
RTS Batteries
• Re-analysis: Passing RTS batteries• Decreased risk of further knee injury by
72% • Decreased odds of any ACL injury by
75%• Decreased odds of ACL graft rupture by
78%
• High risk• Younger• Higher activity level• Earlier return to sport
Biological Factors
Nagelli Sports Med 2016
Younger population: majority of reinjury within 2 years of ACLR
Relative risk may decrease thereafter
Biological: Allow restoration of baseline joint homeostasis
Resolution of bone bruises (5-12 mos)
Allow graft maturation (HSG 12-24 mos, PTG 6-12)
Neuromuscular improvements up to 24 mos post-ACLR
Psychological Readiness
Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery.
Webster AJSM 2018
Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale
6 Item=12 Item Form
Higher score → Greater subjective readiness
Greater Readiness
Males
Younger
Shorter interval between injury, surgery
Higher frequency pre-injury sport participation
Higher subjective knee scores (IKDC)
Greater limb symmetry
Lower Readiness
Females
Lower subjective knee scores (IKDC)
Psychological Readiness and 2nd ACL
Injury
Psychological Readiness to Return
to Sport Is Associated With Second
Anterior Cruciate Ligament
Injuries.
McPherson AJSM 2019
ACL-RSI
Before surgery
12 months after surgery
329 patients, 52 second ACL injury
Results:
Higher Risk
Younger
Lower ACL-RSI Scale Scores
Lower Risk
90% Sensitivity: 76.7%
RTP
• 4.32x higher re-injury for athletes returning to level 1 sports
• Reinjury rates were “significantly reduced by 51% for each month RTS was
delayed until 9 months after surgery
• Reinjury Rates:
• Failed to pass RTS battery: 38.2% re-injury rate
• Passed all RTS (strength >90%, hop tests): 5.6% re-injury rate.
• More symmetric quadricep strength (>90% symmetry) associated with
lower re-injury rates
Field Tests
T Test
Pro-Agility
Reference:
Preseason
performance
Normative
Data
Returning to the Field
Buckthorpe JOSPT
2019
OFR •On-Field Rehab
RTT •Return to Training
RTC•Return to Competition
RTP •Return to Performance
Secondary “Prevention”
1st Injury: Devastating → 2nd Injury: Life-Changing
What Can I Do? Modify the Modifiable!
Strength
Neuromuscular Re-training
Calculated RTS Timing
Recognize Additional Factors:
Psychological
Concomitant Procedure
Meniscal, Cartilaginous, MLKI
Progressive, graduated rehab & RTP progression
Coordinated, collaborative RTS/RTP decision-making with stakeholders
Primary Prevention
Programs: Sportsmetrics, FIFA 11, 11+, Prevent Injury and Enhance Performance (PEP)
Recommendations: <18 yo male & FEMALE, preseason, multiple times/wk, typically 6+ weeks
Components: strength, proximal control, and plyometric
Conclusion
RTS Testing Battery:
Improve “readiness”, reduce risk
Progressive battery of test most commonly
utilized and supported by evidence
Timing of RTS
Early, Younger: Greater risk
Delaying Factors:
Biological Factors
Psychological Factors
Modify the modifiable
Build a solid foundation
References Webster KE, Nagelli CV, Hewett TE, Feller JA. Factors Associated With Psychological Readiness to Return to Sport After Anterior Cruciate Ligament Reconstruction Surgery. Am J Sports Med. 2018 Jun;46(7):1545-1550.
McPherson AL, Feller JA, Hewett TE, Webster KE. Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injuries. Am J Sports Med. 2019 Mar;47(4):857-862.
Amelia J.H. Arundale, Mario Bizzini, Airelle Giordano, Timothy E. Hewett, David S. Logerstedt, Bert Mandelbaum, David A. Scalzitti, Holly Silvers-Granelli, and Lynn Snyder-Mackler Exercise-Based Knee and Anterior Cruciate Ligament Injury Prevention. Journal of Orthopaedic& Sports Physical Therapy 2018 48:9, A1-A42 .
Capin JJ, et al. Keep calm and carry on testing: a substantive reanalysis and critique of ‘what is the evidence for and validity of return-to-sport testing after anterior cruciate ligament reconstruction surgery? A systematic review and metaanalysis’. Br J Sports Med 2019 Editorial.
Webster KE, Hewett TE. What is the Evidence for and Validity of Return-to-Sport Testing after Anterior Cruciate Ligament Reconstruction Surgery? A Systematic Review and Meta-Analysis. Sports Med. 2019 Jun;49(6):917-929.
Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports Med. 2017 Feb;47(2):221-232.
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul;50(13):804-8.
Garrison JC, Bothwell JM, Wolf G, Aryal, Thigpen CA. Y BALANCE TEST™ ANTERIOR REACH SYMMETRY AT THREE MONTHS IS RELATED TO SINGLE LEG FUNCTIONAL PERFORMANCE AT TIME OF RETURN TO SPORTS FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION. Int J Sports Phys Ther. 2015 Oct; 10(5): 602–611.
Myers H, Christopherson Z, Butler RJ. RELATIONSHIP BETWEEN THE LOWER QUARTER Y-BALANCE TEST SCORES AND ISOKINETIC STRENGTH TESTING IN PATIENTS STATUS POST ACL RECONSTRUCTION. Int J Sports Phys Ther. 2018 Apr; 13(2): 152–159.
Ardern CL, Taylor NF, Feller JA, et al Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors British Journal of Sports Medicine 2014;48:1543-1552.
Lai CCH, Ardern CL, Feller JA, et al Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes British Journal of Sports Medicine 2018;52:128-138.
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. 2016;44(7):1861–1876. doi:10.1177/0363546515621554.
Morgan, M. D., Salmon, L. J., Waller, A., Roe, J. P., & Pinczewski, L. A. (2016). Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. The American Journal of Sports Medicine, 44(2), 384–392. https://doi.org/10.1177/0363546515623032
Timothy E. Hewett, Kate E. Webster, Wendy J. Hurd. Systematic Selection of Key Logistic Regression Variables for Risk Prediction Analyses: A Five Factor Maximum Model. Clin J Sport Med. 2019 Jan; 29(1): 78–85. doi: 10.1097/JSM.0000000000000486
Paterno, MV, Schmitt, LC, Ford, KR. 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. 2010;38(10):1968–1978.
Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field Rehabilitation Part 1: 4 Pillars of High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restoring Sport-Specific Skills, and Progressively Developing Chronic Training Load. J OrthopSports Phys Ther. 2019 Aug;49(8):565-569. doi: 10.2519/jospt.2019.8954. Epub 2019 Jul 10.