Anterior Cruciate Ligament Rehabilitation for the 10- to 18-Year-Old Adolescent Athlete:Practice Guidelines Based on International Delphi Consensus

Background:There are 2 treatment options for adolescent athletes with anterior cruciate ligament (ACL) injuries—rehabilitation alone (nonsurgical treatment) or ACL reconstruction plus rehabilitation. However, there is no clear consensus on how to include strength and neuromuscular training during each phase of rehabilitation.Purpose:To develop a practical consensus for adolescent ACL rehabilitation to help provide care to this age group using an international Delphi panel.Study Design:Consensus statement.Methods:A 3-round online international Delphi consensus study was conducted. A mix of open and closed literature-based statements were formulated and sent out to an international panel of 20 ACL rehabilitation experts. Statements were divided into 3 domains as follows: (1) nonsurgical rehabilitation; (2) prehabilitation; and (3) postoperative rehabilitation. Consensus was defined as 70% agreement between panel members.Results:Panel members agreed that rehabilitation should consist of 3 criterion-based phases, with continued injury prevention serving as a fourth phase. They also reached a consensus on rehabilitation being different for 10- to 16-year-olds compared with 17- and 18-year-olds, with a need to distinguish between prepubertal (Tanner stage 1) and mid- to postpubertal (Tanner stages 2-5) athletes. The panel members reached a consensus on the following topics: educational topics during rehabilitation; psychological interventions during rehabilitation; additional consultation of the orthopaedic surgeon; duration of postoperative rehabilitation; exercises during phase 1 of nonsurgical and postoperative rehabilitation; criteria for progression from phase 1 to phase 2; resistance training during phase 2; jumping exercises during phase 2; criteria for progression from phase 2 to phase 3; and criteria for return to sports (RTS). The most notable differences in recommendations for prepubertal compared with mid- to postpubertal athletes were described for resistance training and RTS criteria.Conclusion:Together with available evidence, this international Delphi statement provides a framework based on expert consensus and describes a practice guideline for adolescent ACL rehabilitation, which can be used in day-to-day practice. This is an important step toward reducing practice inconsistencies, improving the quality of rehabilitation after adolescent ACL injuries, and closing the evidence-practice gap while waiting for further studies to provide clarity

Patient-reported outcome measures for hip-related pain: A review of the available evidence and a consensus statement from the International Hip-related Pain Research Network, Zurich 2018

Hip-related pain is a well-recognised complaint among active young and middle-aged active adults. People experiencing hip-related disorders commonly report pain and reduced functional capacity, including difficulties in executing activities of daily living. Patient-reported outcome measures (PROMs) are essential to accurately examine and compare the effects of different treatments on disability in those with hip pain. In November 2018, 38 researchers and clinicians working in the field of hip-related pain met in Zurich, Switzerland for the first International Hip-related Pain Research Network meeting. Prior to the meeting, evidence summaries were developed relating to four prioritised themes. This paper discusses the available evidence and consensus process from which recommendations were made regarding the appropriate use of PROMs to assess disability in young and middle-aged active adults with hip-related pain. Our process to gain consensus had five steps: (1) systematic review of systematic reviews; (2) preliminary discussion within the working group; (3) update of the more recent high-quality systematic review and examination of the psychometric properties of PROMs according to established guidelines; (4) formulation of the recommendations considering the limitations of the PROMs derived from the examination of their quality; and (5

Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: a prospective MRI study

Background: The increased risk of long-term osteoarthritis from concomitant injuries to the menisci or cartilage after an anterior cruciate ligament (ACL) injury in adults is well established. In skeletally immature children, ACL reconstruction is often recommended to reduce the risk of new intra-articular injuries. However, the prevalence and incidence of new injuries after nonoperative treatment of ACL injuries in children are unknown. Purpose: To prospectively investigate the incidence of new injuries to the menisci and joint cartilage in nonoperatively treated, skeletally immature children with a known ACL injury by use of bilateral 3.0-T MRI. Study Design: Case series; Level of evidence, 4. Methods: Forty skeletally immature children with a ruptured ACL (41 knees) followed a nonoperative treatment algorithm and were evaluated with bilateral 3.0-T MRI on 2 occasions (MRI1 and MRI2). The intra-articular structures were analyzed by 2 independent MRI radiologists. Monitoring of participation in physical activities was accomplished through a monthly online activity survey. Descriptive statistics and frequencies were extracted from the scoring forms and compared using the Fisher exact test. Results: Fourteen girls (35%) and 26 boys (65%) with a mean age of 11.0 ± 1.4 years at the time of injury were included. Time from injury to the final follow-up was 3.8 ± 1.4 years. Eighty-eight percent of the ACL-deficient children confirmed monthly participation in pivoting sports and/or in physical education classes in school. The prevalence of meniscus injuries in the 28 nonreconstructed knees was 28.5% at MRI1 and MRI2, and the incidence of new meniscus and cartilage injuries in the nonreconstructed knees from MRI1 to MRI2 was 3.6%. Thirteen children underwent ACL reconstruction, with a prevalence of meniscus procedures of 46.2%. The incidence of new meniscus injuries from diagnostic MRI to final follow-up was 19.5%. Surgical treatments for meniscus injuries were performed in 8 of the 41 knees. Conclusion: The incidence of new injuries to menisci and joint cartilage was low between MRI1 and MRI2 in the 28 nonreconstructed knees. Thirty-two percent of the knees required ACL reconstruction, and 19.5% required meniscus surgeries during the 3.8 ± 1.4 years of follow-up from injury. Further follow-up is needed to evaluate the long-term knee health in these children

Prevalence and incidence of new meniscus and cartilage injuries after a nonoperative treatment algorithm for ACL tears in skeletally immature children: a prospective MRI study

I Brage finner du siste tekst-versjon av artikkelen, og den kan inneholde ubetydelige forskjeller fra forlagets pdf-versjon. Forlagets pdf-versjon finner du på www.sage.com: http://dx.doi.org/10.1177/0363546513491092 / In Brage you'll find the final text version of the article, and it may contain insignificant differences from the journal's pdf version. The original publication is available at www.sage.com: http://dx.doi.org/10.1177/0363546513491092Background: The increased risk of long-term osteoarthritis from concomitant injuries to the menisci or cartilage after an anterior cruciate ligament (ACL) injury in adults is well established. In skeletally immature children, ACL reconstruction is often recommended to reduce the risk of new intra-articular injuries. However, the prevalence and incidence of new injuries after nonoperative treatment of ACL injuries in children are unknown. Purpose: To prospectively investigate the incidence of new injuries to the menisci and joint cartilage in nonoperatively treated, skeletally immature children with a known ACL injury by use of bilateral 3.0-T MRI. Study Design: Case series; Level of evidence, 4. Methods: Forty skeletally immature children with a ruptured ACL (41 knees) followed a nonoperative treatment algorithm and were evaluated with bilateral 3.0-T MRI on 2 occasions (MRI1 and MRI2). The intra-articular structures were analyzed by 2 independent MRI radiologists. Monitoring of participation in physical activities was accomplished through a monthly online activity survey. Descriptive statistics and frequencies were extracted from the scoring forms and compared using the Fisher exact test. Results: Fourteen girls (35%) and 26 boys (65%) with a mean age of 11.0 ± 1.4 years at the time of injury were included. Time from injury to the final follow-up was 3.8 ± 1.4 years. Eighty-eight percent of the ACL-deficient children confirmed monthly participation in pivoting sports and/or in physical education classes in school. The prevalence of meniscus injuries in the 28 nonreconstructed knees was 28.5% at MRI1 and MRI2, and the incidence of new meniscus and cartilage injuries in the nonreconstructed knees from MRI1 to MRI2 was 3.6%. Thirteen children underwent ACL reconstruction, with a prevalence of meniscus procedures of 46.2%. The incidence of new meniscus injuries from diagnostic MRI to final follow-up was 19.5%. Surgical treatments for meniscus injuries were performed in 8 of the 41 knees. Conclusion: The incidence of new injuries to menisci and joint cartilage was low between MRI1 and MRI2 in the 28 nonreconstructed knees. Thirty-two percent of the knees required ACL reconstruction, and 19.5% required meniscus surgeries during the 3.8 ± 1.4 years of follow-up from injury. Further follow-up is needed to evaluate the long-term knee health in these children.Seksjon for idrettsmedisinske fag / Department of Sports Medicin

Performance-based functional outcome for children 12 years or younger following anterior cruciate ligament injury : a two to nine-year follow-up study.

There is limited scientific knowledge on ACL injuries in children 12 years or younger. Substantial controversy exists on treatment algorithms and there are no published data on performance based functional outcome. Classification of adult ACL injured subjects as copers and non-copers is common, but no study has classified knee function in children using performance based functional test after ACL injury. The aim of the present study was to evaluate the long term functional outcome among children with ACL injury, and to classify them as copers and non-copers. Children 12 years or younger who were referred to our institution from 1996 to 2004 with an ACL injury were included. Twenty non-operated subjects (21 knees) and six ACL reconstructed subjects (7 knees) were examined at a minimum of two years after ACL injury or reconstruction. Four single legged hop tests, isokinetic muscle strength measurements, and three functional questionnaires (IKDC 2000, KOS-ADLS and Lysholm) were used as outcome measurements. Children who had resumed their pre-injury activity level and performed above 90% on all hop tests were classified as copers following non-operative treatment and ACL reconstruction. The 26 children were on average 10.1 years at time of injury. Sixty-five percent of the nonoperated children had returned to pre-injury activity level, and 50% were classified as copers. Copers scored significantly better than non-copers on single hop for distance, IKDC 2000, and Lysholm score. Nine and a half percent of the non-operated children had suffered a secondary meniscus injury. Sixty-seven percent of the ACL reconstructed subjects were classified as copers at follow-up. Non-operated ACL-deficient children demonstrated excellent knee function on performance based single legged hop tests and 65% had returned to pre-injury activity level. Delayed ACL reconstruction resulted in success for a majority of the ACL reconstructed children. Treatment algorithms for ACL injured children are discussed

Total Rupture of the Anterior Cruciate Ligament: Testing of Function, Rehabilitation, and Long Term Implications

Rupture of the anterior cruciate ligament (ACL) is a serious knee injury that annually affects approximately 4000 individuals in Norway; of which about fifty percent go through reconstructive surgery. An ACL rupture may lead to instability and poor knee function. In the long term, the injury may permanently preclude return to previous activity level and pose an increased risk for later development of knee osteoarthritis. Today, no definite guidelines for the best treatment and rehabilitation after ACL-rupture exist; neither for non-operative treatment or rehabilitation after reconstruction. In this article we present our rehabilitation protocol for ACL injured patients treated at Hjelp24 NIMI/NAR. Based on our own principles, we then address important aspects physiotherapists should be aware of when involved in ACL rehabilitation: Advantages and possible pitfalls related to reconstruction, expected function after rehabilitation, whether we should recommend the patient to return to his or her previous level of activity or not, and risk factors for the development of knee osteoarthritis

Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years’ Follow-up

Background: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. Purpose: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. Study Design: Case series; Level of evidence, 4. Methods: Forty-six children aged 90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. Conclusion: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery

Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years’ Follow-up

Background: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. Purpose: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. Study Design: Case series; Level of evidence, 4. Methods: Forty-six children aged 90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. Conclusion: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery

Rehabilitation after anterior cruciate ligament injury influences joint loading during walking but not hopping

Objective: The purpose of this study was to identify changes in clinical outcome and lower extremity biomechanics during walking and hopping in ACL-injured subjects before and after a 20-session neuromuscular and strength training programme. Study design: Pre and post experimental design. Setting: Outpatient clinic, primary care. Patients: 32 subjects with unilateral ACL injury, mean 60 (SD 35) days after injury, with a mean age of 26.2 (5.4) years. Intervention: The rehabilitation programme consisted of neuromuscular and strength exercises. Main outcome measurements: Outcome measurements assessed before and after a 20-session rehabilitation programme were: self-assessment questionnaires (KOS-ADL, IKDC2000, Global function), four single-leg hop tests, and isokinetic muscle strength tests. Lower extremity kinematics and kinetics were captured during the stance phase of gait and landing after a single leg hop, synchronised with three force plates. Results: These ACL-injured individuals significantly improved their clinical outcome after rehabilitation. Gait analysis disclosed a significantly improved knee extension moment after rehabilitation, but no change in hip or knee excursions. During landing after hop no change in knee excursion or knee moment was recorded. Conclusion: After rehabilitation the ACL-injured subjects showed a significantly improved clinical outcome, but lower extremity biomechanics were still significantly impaired during both walking and hopping. The rehabilitation programme influenced knee joint loading during walking, but not during hopping. Longer rehabilitation should be considered before ACL-injured individuals return to jumping activities