Disparities in ACL Reconstruction: the Influence of Gender and Race on Incidence, Treatment, and Outcomes

Abstract Purpose of Review Anterior cruciate ligament (ACL) rupture is a common injury that has important clinical and economic implications. We aimed to review the literature to identify gender, racial and ethnic disparities in incidence, treatment, and outcomes of ACL injury. Recent Findings Females are at increased risk for ACL injury compared to males. Intrinsic differences such as increased quadriceps angle and increased posterior tibial slope may be contributing factors. Despite lower rates of injury, males undergo ACL reconstruction (ACLR) more frequently. There is conflicting evidence regarding gender differences in graft failure and ACL revision rates, but males demonstrate higher return to sport (RTS) rates. Females report worse functional outcome scores and have worse biomechanical metrics following ACLR. Direct evidence of racial and ethnic disparities is limited, but present. White athletes have greater risk of ACL injury compared to Black athletes. Non-White and Spanish-speaking patients are less likely to undergo ACLR after ACL tear. Black and Hispanic youth have greater surgical delay to ACLR, increased risk for loss to clinical follow-up, and less physical therapy sessions, thereby leading to greater deficits in knee extensor strength during rehabilitation. Hispanic and Black patients also have greater risk for hospital admission after ACLR, though this disparity is improving. Summary Females have higher rates of ACL injury with inconclusive evidence on anatomic predisposition and ACL failure rate differences between genders. Recent literature has suggested inferior RTS and functional outcomes following ACLR in females. Though there is limited and mixed data on incidence and outcome differences between races and ethnic groups, recent studies suggest there may be disparities in those who undergo ACLR and time to treatment.

Download Full-text

Current Return to Sport Criteria after ACL Reconstruction Fail to Identify Increased Risk of Second ACL Injury in Young Athletes

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00060 ◽

2018 ◽

Vol 6 (7_suppl4) ◽

pp. 2325967118S0006 ◽

Cited By ~ 2

Author(s):

Mark V. Paterno ◽

Mitchell Rauh ◽

Staci Thomas ◽

Timothy E. Hewett ◽

Laura Schmitt

Keyword(s):

Acl Reconstruction ◽

Group Analysis ◽

Return To Sport ◽

Acl Injury ◽

Quadriceps Strength ◽

Patient Reported Outcome ◽

Young Athletes ◽

Increased Risk ◽

Significant Difference ◽

Patient Reported

Objectives: The incidence of 2nd anterior cruciate ligament (ACL) injury after ACL reconstruction (ACLR) and return to sport (RTS) ranges from 25%-33% in young, active populations; with the greatest risk in the first 12 months after RTS. Recent data indicate that failure to successfully meet traditional RTS criteria, inclusive of strength, functional hop testing and patient reported outcome scores, may identify athletes at increased risk of future injury after ACLR. However, these studies have focused on adult populations and it is unknown if similar RTS criteria apply to young, adolescent, pivoting/cutting athletes. The purpose of this study was to determine if meeting all current, standard RTS criteria would identify young athletes at risk for future ACL injury after primary ACLR and RTS. The tested hypothesis was the likelihood of 2nd ACL injury in the first 2 years after RTS would be lower in patients who met all RTS criteria prior to initiation of pivoting and cutting activity compared to patients who failed to meet all RTS criteria prior to RTS. Methods: One hundred fifty-nine subjects (112 female, 47 male) with a mean age of 17.2±2.6 years old (range: 13-25 y.o.) underwent ACLR and were released to return to pivoting/cutting sport. These patients were enrolled in a prospective, observational cohort study, completed a RTS assessment and were then tracked for occurrence of 2nd ACL after ACLR for 24 months. The RTS assessment included 6 tests: isometric quadriceps strength, 4 functional hop tests and the International Knee Documentation Committee (IKDC) patient reported outcome survey. Limb symmetry index (LSI) was calculated for strength and hop test assessments [(involved/uninvolved)*100]. The IKDC was reported on a 0-100 scale with 100 representing a perfect score. Subjects were classified into groups that successfully passed all 6 RTS tests at a level of 90 and again at 95 compared to those that failed to meet all 6 criteria. Chi Square tests were used to determine if successfully passing all 6 RTS measures at various levels of symmetry resulted in a reduced risk of 2nd ACL injury in the first 24 months after RTS. Results: Thirty-five (22.0%) patients suffered a 2nd ACL injury, with 26 occurring in the first 12 months after RTS. At the time of RTS, 42 patients (26%) achieved LSI values of 90 or greater on all testing as well as an IKDC value of 90 or greater. The remaining 117 subjects (74%) scored below 90 on at least 1 of the 6 assessments. At this level, there was no difference in 2nd ACL injury prevalence between patients who passed all RTS criteria (12/42; 28.6%) and those who failed at least 1 criteria (23/117; 19.7%) (p=0.23). When the passing criteria was elevated to 95 on all RTS testing, only 15 subjects (9%) successfully passed all 6 tests. There was no significant difference in 2nd ACL injury prevalence between patients who passed all RTS criteria (5/15; 33%) and those who failed at least 1 test (30/144; 20.8%) (p=0.32). Sub-group analysis which evaluated the group by graft type, also indicated no significant differences between groups (p>0.05). Conclusion: Current criteria to evaluate readiness to return young athletes to pivoting and cutting sports, using quadriceps strength symmetry, functional hop performance symmetry and patient reported outcomes, may not identify young, active patients at high risk for 2nd ACL injury. Future work must identify more appropriate criteria to assess readiness to RTS in the young, athletic population and incorporate these findings into practice.

Download Full-text

ACL INJURY AND RETURN TO SPORT

European Journal of Health & Science in Sports ◽

10.33598/v8i2202177 ◽

2021 ◽

Vol 8 (2) ◽

pp. 6-15

Author(s):

Dorian Meta ◽

◽

Ilia Mazniku ◽

Keyword(s):

Acl Reconstruction ◽

Bone Scan ◽

Cruciate Ligament ◽

Meniscal Tear ◽

Return To Sport ◽

Sports Participation ◽

Acl Injury ◽

Joint Surface ◽

Functional Rehabilitation ◽

Number Of Patients

We followed 110 patients who had sustained an acute traumatic Haemarthrosis for a mean of 60 months. The arthrometer measurements within 90 days of injury revealed the injured knee was stable in 35 patients and unstable in 75. Thirty-five unstable patients had an ACL reconstruction within 90 days of injury. Surgical procedures performed >90 days after injury included ligament reconstruction in 35 patients. Factors that correlated with patients who had late surgery for a meniscal tear or an ACL reconstruction < (P 0.05) were preinjury hours of sports participation, arthrometer measurements, and patient age. Follow-up data are presented for the patient’s divided into four groups: I, early stable, no reconstruction; II, early unstable, no reconstruction; III, early reconstruction; and IV, late reconstruction. No patient changed occupation because of the knee injury. Hours per year of sports participation and levels of sports participation decreased in all groups. Joint arthrosis was documented by radiograph and bone scan. Joint surface injury abnormalities observed at surgery and meniscal surgery showed greater abnormalities by radiograph and bone scan scores (P< 0.05). Reconstructed patients had a higher level of arthrosis by radiograph and bone scan. Anterior cruciate ligament injuries are common. The biggest the number of these injuries occur in sports activities, mainly those that involve deceleration, torsion, shear, and jumping movements. In a study on football team injuries in Albania, reported 2.4 injuries per year on an Albanian university football squad. Many patients remain disabled for sport afterwards an ACL injury; others appear to have minimal damage. Some patients develop secondary and degenerative meniscal ttaears knee arthritis; others show little joint deterioration. Few studies have documented the incidence of late meniscal tears after an ACL injury. Due to the variability of patient impairment after ACL injury and the lack of documentation that ACL surgery prevents degenerative arthritis, controversy over indications for ligament surgery. Moreover, a large number of patients do not often follow the entire functional rehabilitation process. The purpose of this prospective study was to document the outcome of the patient with ACL injury and the search for factors identifiable immediately after the injury correlating with a greater risk of functional impairment, secondary meniscus tears and joint arthrosis.

Download Full-text

A Tomahawk Shaped Femur is a Risk Factor for Anterior Cruciate Ligament Injury

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00016 ◽

2018 ◽

Vol 6 (4_suppl2) ◽

pp. 2325967118S0001

Author(s):

Thomas Pfeiffer ◽

Jeremy Burnham ◽

Elmar Herbst ◽

Sven Shafizadeh ◽

Volker Musahl

Keyword(s):

Acl Reconstruction ◽

Roc Analysis ◽

Cruciate Ligament ◽

Acl Injury ◽

Control Group ◽

Acl Injuries ◽

Injury Group ◽

Increased Risk ◽

The Mean ◽

Anterior Cruciate

Bony morphologic characteristics have been demonstrated to increase the risk of anterior cruciate ligament (ACL) injury. The purpose of the study was to examine distal femoral morphology relative to ACL injury, reconstruction failure, and contralateral ACL injury. It was hypothesized that an increased posterior femoral condylar depth, quantified as the tomahawk ratio, would correlate with increased risk of primary ACL ruptures, ACL reconstruction failures, and contralateral ACL injuries. Consecutive patients undergoing arthroscopic knee surgery at an academic medical center from 2012-2016 with minimum 24-month follow-up were retrospectively reviewed. Subjects were stratified into four groups: a control group consisting of patients with no ACL injuries and three groups of patients with a primary ACL injury, failed ACL reconstruction, or previous ACL injury with subsequent contralateral ACL injury. Using lateral radiographs, the ratio of posterior condylar depth over total condylar distance was defined as the tomahawk ratio. Analysis-of-variance (ANOVA) and post-hoc testing were used to test for differences in the mean tomahawk ratio between study groups (p<0.05). Receiver Operating Characteristic (ROC) analysis was performed to determine the optimal tomahawk ratio cut-off for detecting increased risk for ACL injury 175 patients met inclusion criteria. The mean tomahawk ratios in the control group, primary ACL injury group, failed ACL reconstruction group, and contralateral ACL injury group were 61.1% (± 2.1), 64.2% (± 3.8), 64.4% (± 3.6), and 66.9% (± 4.0), respectively. Patients with a primary ACL injury, failed ACL reconstruction, or contralateral ACL injury had a significantly higher tomahawk ratio compared to the control group (p<0.008). ROC analysis demonstrated a tomahawk ratio of 63% or greater to be associated with an increased risk for ACL injury with a sensitivity of 83% and a specificity of 71%. The data from this study show that an increased posterior femoral condylar depth, or tomahawk ratio, is associated with increased risk of ACL injury, including primary ACL injury, failed ACL reconstruction, and contralateral ACL injury. Readily identifiable risk factors, such as an increased tomahawk ratio, could assist clinicians in identifying at-risk individuals who may experience greater benefit from targeted ACL injury prevention counseling and intervention. The presence of the tomahawk-shaped femur could also be used to guide treatment decisions and identify ACL reconstruction patients who may benefit from additional surgical procedures such as extra articular tenodesis.

Download Full-text

Smaller Change in Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injury Among Younger Patients

The American Journal of Sports Medicine ◽

10.1177/0363546519825499 ◽

2019 ◽

Vol 47 (5) ◽

pp. 1209-1215 ◽

Cited By ~ 11

Author(s):

April L. McPherson ◽

Julian A. Feller ◽

Timothy E. Hewett ◽

Kate E. Webster

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Young Patients ◽

Return To Sport ◽

Acl Injury ◽

Short Version ◽

Younger Patients ◽

Anterior Cruciate ◽

Injured Patients

Background: Lower psychological readiness to return to sport has been reported for younger patients (≤20 years) who go on to a second anterior cruciate ligament (ACL) injury. However, changes in psychological readiness and specific psychological responses associated with second injury have not been identified. Purpose/Hypothesis: To identify changes in psychological readiness over time associated with a second ACL injury. It was hypothesized that younger patients who suffered a second injury would have smaller changes in psychological readiness to return to sport when compared with those who did not have a second injury. Study Design: Case-control study; Level of evidence, 2. Methods: Patients ≤20 years old at the time of surgery who had a primary ACL reconstruction procedure between June 2014 and June 2016 were recruited for this study. The short version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale was completed by patients before their ACL reconstruction and repeated at 12 months after surgery to assess psychological readiness to return to sport. The primary outcome of interest was the relationship between the change in psychological readiness and second ACL injuries. Results: Among 115 young patients who returned to sport after ACL reconstruction, 21 (18%) experienced a second ACL injury. Injured patients did not show improvement in their ACL-RSI score between the preoperative assessment and 12-month time point (58.5 vs 60.8 points, P = .60) and had a significantly smaller change when compared with noninjured patients (9.2 vs 24.9 points, P = .01). When compared with the noninjured group, the injured group reported they were more nervous about playing sport, less confident in playing sport without concern for the knee, more frustrated with having to consider the knee with respect to sport, and more fearful of reinjuring the knee by playing sport ( P≤ .05). Conclusion: Injured patients exhibited less improvement in psychological readiness at a group level and reported different psychological characteristics with regard to return to sport at 12 months after ACL reconstruction as monitored by the ACL-RSI scale.

Download Full-text

Quadricep Femoris Strength at Return to Sport Identifies Limb at Increased Risk of Future ACL Injury after ACL Reconstruction in Young Athletes

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00329 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0032

Author(s):

Mark V. Paterno ◽

Mitchell J. Rauh ◽

Staci Thomas ◽

Timothy E. Hewett ◽

Laura C. Schmitt

Keyword(s):

High Risk ◽

Acl Reconstruction ◽

Graft Failure ◽

Return To Sport ◽

Acl Injury ◽

Quadriceps Strength ◽

Young Athletes ◽

Increased Risk ◽

Active Patients ◽

Reduced Risk

Objectives: The ability of current return to sport (RTS) criteria to identify young, active patients after ACL reconstruction (ACLR) independently, at high risk for future ipsilateral or contralateral ACL injury is limited. The purpose of this study was to determine if meeting current, standard RTS criteria collectively, or in part, would identify young athletes at risk for an ipsilateral or contralateral ACL injury after primary ACLR and RTS. The tested hypothesis was the likelihood of an ipsilateral or contralateral 2nd ACL injury in the first 2 years after RTS would be the same in groups that successfully met or failed to meet all RTS criteria prior to RTS. The second hypothesis was that quadriceps femoris strength at the time of RTS would identify which limb was at greatest risk for future ACL injury. Methods: One hundred eighty-one patients (116 female) with a mean age of 16.7±2.9 years old underwent ACLR and were released to return to pivoting/cutting sports. These patients were enrolled in a prospective, observational cohort study, completed a RTS assessment and were tracked for occurrence of an ipsilateral graft tear or contralateral ACL injury after ACLR for 24 months. The RTS assessment included 6 tests: isometric quadriceps strength, 4 functional hop tests and the International Knee Documentation Committee (IKDC) patient reported outcome survey. Limb symmetry index (LSI) was calculated for strength and hop test assessments [(inv/uninv)*100]. Subjects were classified into groups that successfully passed all 6 RTS tests at a level of 90 compared to those that failed to meet all 6 criteria. Chi Square tests and Fisher Exact Tests were used to determine if successfully passing all 6 RTS measures resulted in a reduced risk of 2nd ACL injury in the first 24 months after RTS as well as to assess if ability to successfully pass individual RTS criteria resulted in reduced risk of 2nd ACL injury. Results: Thirty-nine (21.5%) patients suffered a 2nd ACL injury with 18 ipsilateral graft failures and 21 contralateral ACL tears in the first 24 months after RTS following ACLR. At the time of RTS, 57 patients (31.5%) achieved LSI values of 90% or greater on all testing as well as an IDKC value of 90 or greater. At this level, there was no difference in ipsilateral graft failures between patients who passed all RTS criteria (15.8%) and those who failed at least 1 criterion (7.3%; p=0.08). There was also no difference in contralateral ACL injuries between patients who passed all RTS criteria (7.0%) and those who failed at least 1 criterion (13.7%; p=0.22). When individual RTS criterion were evaluated, patients who failed to achieve 90% quadriceps strength LSI were 84% less likely to suffer an ipsilateral graft failure (OR=0.16; 95%CI: 0.04, 0.74;p=0.009), but 3 times more likely to suffer a contralateral ACL injury (OR=2.5; 95%CI:1.0, 6.5;p=0.05). Conclusion: Current criteria to evaluate readiness to return young athletes to pivoting and cutting sports, may not identify young, active patients independently at high risk for a future ipsilateral graft tear or contralateral ACL injury. Inability to achieve 90% LSI on an isometric quadriceps strength assessment resulted in a reduced risk of ipsilateral graft failure, but an increased risk in contralateral ACL injury after ACLR and RTS. Further investigation is needed on the relationship between quad strength and side of future ACL injury and whether other factors may help contribute to a predictive model of future ACL injury specific to limb.

Download Full-text

Incidence of Contralateral and Ipsilateral Anterior Cruciate Ligament (ACL) Injury After Primary ACL Reconstruction and Return to Sport

Clinical Journal of Sport Medicine ◽

10.1097/jsm.0b013e318246ef9e ◽

2012 ◽

Vol 22 (2) ◽

pp. 116-121 ◽

Cited By ~ 235

Author(s):

Mark V. Paterno ◽

Mitchell J. Rauh ◽

Laura C. Schmitt ◽

Kevin R. Ford ◽

Timothy E. Hewett

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Return To Sport ◽

Acl Injury ◽

Anterior Cruciate ◽

Primary Acl Reconstruction

Download Full-text

Return to sport outcomes in the younger patient with anterior cruciate ligament reconstruction

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967117s00173 ◽

2017 ◽

Vol 5 (5_suppl5) ◽

pp. 2325967117S0017

Author(s):

TS Whitehead ◽

JA Feller ◽

KE Webster

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Return To Sport ◽

Acl Injury ◽

Younger Patients ◽

Reconstruction Surgery ◽

Anterior Cruciate ◽

Work Commitments

Objective: Anterior cruciate ligament (ACL) reconstruction is generally regarded as a successful procedure, however only 65% of patients return to their pre-injury sport. While return to sport rates are likely higher in younger patients, there is a paucity of data on this topic. The purpose of this study was to investigate a range of return to sport outcomes in younger athletes who had undergone ACL reconstruction surgery. Methods: This was a cross-sectional study design. A group of 140 young patients (<20 years at surgery) who had one ACL reconstruction and no subsequent ACL injuries were surveyed regarding details of their sport participation at an average follow up of 5 years (range 3-7). Results: Overall, 76% of the young patient group returned to the same pre-injury sport. Return rates were higher for males than females (81% vs. 71% respectively, p>0.05). Of those who returned to their sport, 65% reported that they could perform as well as before the ACL injury and 66% were still currently playing in their respective sport. Young athletes who never returned to sport cited fear of a new injury (37%) or study/work commitments (30%) as the primary reasons. For those who had successfully returned to their pre-injury sport but subsequently stopped playing, the most common reason was study/work commitments (53%). At follow-up 48% of female patients were still participating in Level I sports as were 54% of males. Conclusions: A high percentage of younger patients return to their pre-injury sport following ACL reconstruction surgery. For this group who have not sustained a second ACL injury, the majority continue to play and are satisfied with their performance.

Download Full-text

ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline

Sports Health A Multidisciplinary Approach ◽

10.1177/19417381211056873 ◽

2021 ◽

pp. 194173812110568

Author(s):

Alexander W. Brinlee ◽

Scott B. Dickenson ◽

Airelle Hunter-Giordano ◽

Lynn Snyder-Mackler

Keyword(s):

Injury Prevention ◽

Acl Reconstruction ◽

Clinical Data ◽

Practice Guidelines ◽

Cruciate Ligament ◽

Return To Sport ◽

Acl Injury ◽

Quadriceps Strength ◽

Kinetic Chain ◽

Open Kinetic Chain

Context: Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians’ current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice. Evidence Acquisition: Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention. Study Design: Clinical review. Level of Evidence: Level 5. Results: Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey–Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline. Conclusion: Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport. Strength of Recommendation Taxonomy (SORT): B.

Download Full-text

Clinical Risk Profile for a Second Anterior Cruciate Ligament Injury in Female Soccer Players After Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546521999109 ◽

2021 ◽

pp. 036354652199910

Author(s):

Anne Fältström ◽

Joanna Kvist ◽

Natalia F.N. Bittencourt ◽

Luciana D. Mendonça ◽

Martin Hägglund

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Return To Sport ◽

Acl Injury ◽

Soccer Players ◽

Factors Associated ◽

Cart Analysis ◽

Jump Test ◽

Anterior Cruciate

Background: The risk of a second anterior cruciate ligament (ACL) injury when participating in pivoting sports after ACL reconstruction is high. Risk factors associated with a second ACL injury are complex. Purpose: To investigate the combinations of various clinical risk factors associated with second ACL injury in female soccer players with a primary unilateral ACL reconstruction, using Classification and Regression Tree (CART) analysis. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 117 active female soccer players (mean ± SD age, 20 ± 2 years) were included. Athletes were enrolled 19 ± 9 months after ACL reconstruction and were prospectively followed for 2 years. At baseline, all players underwent assessment of knee and ankle joint range of motion (ROM), participated in functional tests (postural control, hop performance, and movement asymmetries in the lower limbs and trunk), and answered questionnaires (patient-reported knee function, knee-related quality of life, psychological and personality factors). A clinical prediction model using CART was developed. Results: A total of 28 players (24%) sustained a second ACL injury (21 ipsilateral and 7 contralateral ruptures) while playing soccer. CART analysis selected 9 of 19 independent variables associated with second ACL injury: the 5-jump test, knee collapse on the non–ACL reconstructed leg in a drop vertical jump, tuck jump, limb symmetry index on side hop and the single hop for distance, side difference in ankle dorsiflexion ROM, and scores for the questionnaires ACL-Return to Sport After Injury and the Swedish Universities Scales of Personality subscales of Stress Susceptibility and Adventure Seeking. The accuracy of the model was 89%, with 100% sensitivity and 76% specificity. CART analysis indicated that the interaction of longer jumps in the 5-jump test (>916 cm) with more side difference in ankle dorsiflexion ROM (>–2.5°) and more knee valgus collapse in the nonreconstructed knee (>−1.4 cm) (relative risk, 4.03; 95% CI, 2.21-7.36) best predicted an increased likelihood of a second ACL injury. Conclusion: The risk profiles selected by CART could accurately identify female soccer players at high risk for a second ACL injury. There was an interaction between functional performance, clinical assessment, and psychological factors, and it is reasonable to include these factors in return-to-sport decisions and in athlete screening after ACL injury.

Download Full-text