Development and Validation of a Short Version of the Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) Scale

Background: The Anterior Cruciate Ligament Return to Sport After Injury (ACL-RSI) scale was developed to measure an athlete’s psychological readiness to return to sport after anterior cruciate ligament (ACL) injury and reconstruction surgery. The scale is being used with increasing frequency in both research and clinical settings. Purpose: To generate and validate a short version of the ACL-RSI scale. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The ACL-RSI scale was administered to 535 patients who had undergone ACL reconstruction surgery. Reliability (Cronbach alpha) was determined and factor analysis of the full scale was undertaken along with a process of item selection and elimination. A second group of 250 patients participated in a predictive validation analysis. This group completed the ACL-RSI scale at 6 months and reported return-to-sport outcomes 12 months following ACL reconstruction surgery. The predictive validity of both scales (full and short versions) was assessed by use of receiver operating characteristic (ROC) curve statistics. Results: The scale was found to have high internal consistency (Cronbach alpha, 0.96), which suggested that item redundancy was present. After an item selection process, the scale was reduced to a 6-item format. Cronbach alpha for the short version was 0.92, and factor analysis confirmed the presence of 1 factor accounting for 71% of the total variance. Scores for the short version were significantly different between patients who had and those who had not returned to sport. Six-month ACL-RSI scores for both the full and short versions had fair to good predictive ability for 12-month return-to-sport outcomes (full version: area under ROC curve, 0.77 [95% CI, 0.7-0.8]; short version: area under ROC curve, 0.75 [95% CI, 0.7-0.8]). Conclusion: A 6-item short version of the ACL-RSI scale was developed from a large cohort of patients undergoing ACL reconstruction. The short version appears to be as robust as the full version for discriminating between and predicting return-to-sport outcomes. The short version of the ACL-RSI may be of use in busy clinical settings to help identify athletes who may find return to sport challenging.

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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.

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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.

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Factors Associated With a Return to Preinjury Level of Sport Performance After Anterior Cruciate Ligament Reconstruction Surgery

The American Journal of Sports Medicine ◽

10.1177/0363546519865537 ◽

2019 ◽

Vol 47 (11) ◽

pp. 2557-2562 ◽

Cited By ~ 15

Author(s):

Kate E. Webster ◽

April L. McPherson ◽

Timothy E. Hewett ◽

Julian A. Feller

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Sport Participation ◽

Cruciate Ligament ◽

Return To Sport ◽

Sport Performance ◽

Activity Level ◽

Age Difference ◽

Reconstruction Surgery ◽

Anterior Cruciate

Background: Many studies have investigated factors that predict a return to sport participation after anterior cruciate ligament (ACL) reconstruction, but it is unclear whether the same factors are associated with a return to preinjury level of sport performance. Purpose: To identify factors that contribute to an athlete’s return to preinjury level of performance after ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: A cohort of 222 patients (132 male, 90 female) who had ACL reconstruction surgery and completed a 12-month postoperative assessment were followed out to a mean 3 years (range, 2-4 years) to determine whether they had returned to their self-reported preinjury levels of sport performance. Rates of return to preinjury performance were calculated. Measures that had been recorded at the 12-month postoperative review—demographic (age, sex), sport activity level (Marx Activity Rating Scale, return to competition sport), knee laxity, limb symmetry (single and triple crossover hop), subjective function/symptoms (International Knee Documentation Committee subjective), and psychological readiness (Anterior Cruciate Ligament Return to Sport After Injury scale)—were compared between patients who returned to their preinjury levels of performance and those who did not. Univariate and multivariate logistic regression models were also used to prospectively determine the association between these measures and return to preinjury level of sport performance. Results: A total of 135 (61%) patients reported that they had returned to their preinjury levels of performance, with return rates similar between males (59%) and females (63%) and between those who had returned to competition at 12 months (62%) and those who had not (60%). There was no significant age difference between patients who returned to their preinjury levels of sport performance and those who did not; however, higher psychological readiness ( P < .0001), greater limb symmetry ( P < .05), higher subjective knee scores ( P = .01), and a higher activity level ( P < .04) were all associated with a return to performance. In the multivariate model, psychological readiness was the only variable that remained a significant predictor (odds ratio = 1.03; 95% CI, 1.01-1.04; P < .0001). Conclusion: A majority of athletes who returned to sport after ACL reconstruction reported that their performance was comparable with preinjury. Having a greater psychological readiness to return during rehabilitation was the most significant predictor of a subsequent return to comparable performance.

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Timeline for Maximal Subjective Outcome Improvement After Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546518803365 ◽

2018 ◽

Vol 47 (10) ◽

pp. 2501-2509 ◽

Cited By ~ 3

Author(s):

Avinesh Agarwalla ◽

Richard N. Puzzitiello ◽

Joseph N. Liu ◽

Gregory L. Cvetanovich ◽

Anirudh K. Gowd ◽

...

Keyword(s):

Systematic Review ◽

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Clinical Significance ◽

Cruciate Ligament ◽

Return To Sport ◽

Pubmed Database ◽

Patient Reported ◽

Clinically Significant ◽

Anterior Cruciate

Background: Anterior cruciate ligament (ACL) tears are one of the most common traumatic knee injuries experienced by athletes. Return to sport is considered the pinnacle endpoint among patients receiving ACL reconstruction. However, at the time of return to sport, patients may not be participating at their previous levels of function, as defined by clinical metrics. Purpose: To establish when patients perceive maximal subjective medical improvement according to patient-reported outcome measures (PROMs). Study Design: Systematic review. Methods: A systematic review of the PubMed database was conducted to identify studies that reported sequential PROMs up to a minimum of 2 years after ACL reconstruction. Pooled analysis was conducted for PROMs at follow-up points of 3 months, 6 months, 1 year, and 2 years. Clinically significant improvement was determined between pairs of intervals with the minimal clinically important difference. Results: This review contains 30 studies including 2253 patients who underwent ACL reconstruction. Clinically significant improvement in the KOOS (Knee injury and Osteoarthritis Outcome Score) was seen up to 1 year after ACL reconstruction, but no clinical significance was noted from 1 to 2 years. Clinically significant improvement in the IKDC (International Knee Documentation Committee) and Lysholm questionnaires was seen up to 6 months postoperatively, but no clinical significance was noted beyond that. Conclusion: After ACL reconstruction, maximal subjective medical improvement is established 1 year postoperatively, with no further perceived clinical improvement beyond this time point according to current PROMs. The KOOS may be a more responsive metric to subjective improvements in this patient cohort than other patient-reported outcomes, such as the IKDC and Lysholm. Clinical Relevance: After ACL reconstruction, patients perceive interval subjective improvements until 1 year postoperatively.

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Effects of Distally Fixated Versus Nondistally Fixated Leg Extensor Resistance Training on Knee Pain in the Early Period After Anterior Cruciate Ligament Reconstruction

Physical Therapy ◽

10.1093/ptj/82.1.35 ◽

2002 ◽

Vol 82 (1) ◽

pp. 35-43 ◽

Cited By ~ 37

Author(s):

Matthew C Morrissey ◽

Wendy I Drechsler ◽

Dylan Morrissey ◽

Philippa R Knight ◽

Paul W Armstrong ◽

...

Keyword(s):

Anterior Cruciate Ligament ◽

Resistance Training ◽

Acl Reconstruction ◽

Knee Pain ◽

Cruciate Ligament ◽

Early Period ◽

Kinetic Chain ◽

Reconstruction Surgery ◽

Open Kinetic Chain ◽

Anterior Cruciate

Abstract Background and Purpose. Nondistally fixated (ie, what is often referred to as “open kinetic chain” [OKC]) knee extensor resistance training appears to have lost favor for some forms of rehabilitation due partly to concerns that this exercise will irritate the extensor mechanism. In this randomized, single-blind clinical trial, nondistally fixated versus distally fixated (ie, often called “closed kinetic chain” [CKC]) leg extensor training were compared for their effects on knee pain. Subjects. Forty-three patients recovering from anterior cruciate ligament (ACL) reconstruction surgery (34 male, 9 female; mean age=29 years, SD=7.9, range=16–54). Methods. Knee pain was measured at 2 and 6 weeks after ACL reconstruction surgery using visual analog scales in a self-assessment questionnaire and during maximal isometric contractions of the knee extensors. Between test sessions, subjects trained 3 times per week using either OKC or CKC resistance of their knee and hip extensors as part of their physical therapy. Results. No differences in knee pain were found between the treatment groups. Discussion and Conclusion. Open kinetic chain and CKC leg extensor training in the early period after ACL reconstruction surgery do not differ in their immediate effects on anterior knee pain. Based on these findings, further studies are needed using different exercise dosages and patient groups.

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Low Rates of Return to Preinjury Sport After Bilateral Anterior Cruciate Ligament Reconstruction

The American Journal of Sports Medicine ◽

10.1177/0363546518813901 ◽

2018 ◽

Vol 47 (2) ◽

pp. 334-338 ◽

Cited By ~ 4

Author(s):

Kate E. Webster ◽

Julian A. Feller ◽

Alexander J. Kimp ◽

Timothy S. Whitehead

Keyword(s):

Quality Of Life ◽

Acl Reconstruction ◽

Cruciate Ligament ◽

Return To Sport ◽

Rates Of Return ◽

Acl Injuries ◽

Reconstruction Surgery ◽

Anterior Cruciate

Background: Patients with bilateral anterior cruciate ligament (ACL) injuries tend to report worse results in terms of knee function and quality of life as compared with those with unilateral injury. There are limited data regarding return to preinjury sport in this group. Purpose: To report return-to-sport rates for patients who had bilateral ACL reconstruction and to compare outcomes according to age and sex. Study Design: Case series; Level of evidence, 4. Methods: A total of 107 patients (62 male, 45 female) who underwent primary ACL reconstruction surgery to both knees completed a detailed sports activity survey at a mean 5-year follow-up (range, 2.5-10 years). Follow-up also included the International Knee Documentation Committee subjective form, Marx Activity Scale, and Knee injury and Osteoarthritis Outcome Score–Quality of Life subscale. Rates of return to preinjury levels of sport were calculated for the whole cohort, and for further analysis, the group was divided according to age (<25 vs ≥25 years), sex, and time between the reconstruction procedures (<3 vs ≥3 years). Results: The rate of return to preinjury sport after bilateral ACL reconstruction was 40% (95% CI, 31%-50%), as compared with an 83% (95% CI, 74%-88%) return rate after the first reconstruction procedure. Although not statistically significant, return rates were higher for male versus female patients (47% vs 31%) and older versus younger patients (45% vs 31%). Of those who returned to their preinjury levels of sport after the second reconstruction, 72% thought that they could perform as well as before their ACL injuries. In contrast, only 20% thought that they could perform as well if they returned to a lower level. Fear of reinjury was the most common reason cited for failure to return to sport after the second reconstruction. Patient-reported outcome scores were higher for those who returned to their preinjury levels of sport but did not differ for sex and age. Conclusion: Return-to-sport rates drop markedly after a second (contralateral) ACL reconstruction, with less than half of the investigated cohort returning to its preinjury level of sport. Return-to-sport outcomes are less than ideal for patients who have ACL reconstruction surgery to both knees.

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Arabic Version of the Short Anterior Cruciate Ligament–Return to Sport After Injury Scale: Translation, Cross-cultural Adaptation, and Validation

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211066509 ◽

2022 ◽

Vol 10 (1) ◽

pp. 232596712110665

Author(s):

Msaad Alzhrani ◽

Hosam Alzahrani ◽

Yasir S. Alshehri

Keyword(s):

Anterior Cruciate Ligament ◽

Internal Consistency ◽

Cruciate Ligament ◽

Return To Sport ◽

Short Version ◽

Return To Sports ◽

Strongly Correlated ◽

Retest Reliability ◽

Anterior Cruciate ◽

Test Retest Reliability

Background: The short version of the Anterior Cruciate Ligament–Return to Sport After Injury (ACL-RSI) scale is a self-reported questionnaire developed to assess the psychological readiness of patients to return to sports after ACL reconstruction (ACLR). Purpose: To translate, cross-culturally adapt, and validate the short version of the ACL-RSI scale into the Arabic language (ACL-RSI-Ar). Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The original short version of the ACL-RSI scale was forward and backward translated, cross-culturally adapted, and validated following international standardized guidelines. Sixty patients who participated in sports activities and underwent ACLR completed the ACL-RSI-Ar, the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, and Knee injury and Osteoarthritis Outcome Score (KOOS) scales. To assess test-retest reliability, 34 participants completed the ACL-RSI-Ar scale twice. Statistical tests were conducted to test the internal consistency, reliability, and construct and discriminant validity of the ACL-RSI-Ar scale. Results: The ACL-RSI-Ar showed adequate internal consistency (Cronbach alpha = 0.734) and excellent test-retest reliability (intraclass correlation coefficient, 0.871). The ACL-RSI-Ar was strongly correlated with the IKDC (Spearman ρ = 0.515, P < .001) and weakly to strongly correlated with all KOOS subscales (Spearman ρ = 0.247-0.590, P < .05). Patients who returned to sports had significantly higher scores on the ACL-RSI-Ar scale when compared with those who did not return to sports ( P = .001). Conclusion: The short ACL-RSI-Ar scale, as translated, was internally consistent, reliable, and valid for evaluating psychological readiness to return to sports after ACLR in Arabic-speaking patients.

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HOP TEST AS A TOOL FOR THE ASSESSMENT AND PREVENTION OF INJURIES IN FOOTBALLERS DURING PRESEASON

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118s00044 ◽

2018 ◽

Vol 6 (6_suppl3) ◽

pp. 2325967118S0004

Author(s):

F García-Bol ◽

V Posada-Franco ◽

A Roldán-Valero ◽

R Del Caño-Espinel

Keyword(s):

Anterior Cruciate Ligament ◽

Acl Reconstruction ◽

Reference Values ◽

Cruciate Ligament ◽

Return To Sport ◽

Performance Criteria ◽

Return To Sports ◽

Hop Tests ◽

Hop Test ◽

Anterior Cruciate

Hop Tests (unipodal horizontal jumps) have been recommended as one of the reliable assessment tests when allowing a return to competition for a sportsperson after an anterior cruciate ligament injury1,2,3,4. Currently, comparison is made of the results with the contralateral limb through the symmetry index, a method which might not provide sufficient security upon the return to competitive sport5. Hop tests can be used in preseason to gain reference values prior to a possible injury. The objective of this review is to analise the scientific literature such as the F-Marc6 (reference manual of FIFA) to confirm whether include said tests in preseason for football teams. A search was conducted in the Pubmed y Cochrane databases (17/04/17) with the search terms “Hop Test”, “Football”, “Soccer”, and “Preseason”. Articles in English and Spanish were both accepted. Articles excluded were those that did not make reference to the knee, to football, and those that did not conduct tests during preseason. From a total of 33 articles, 4 with these search criteria were included, 5 articles were added trough the bibliography of other studies, and the F-Marc manual was analised. 4 of the articles used the hop tests in preseason for some type of study, of which 3 were used as part of a prospective assessment for the season. On the other hand, the F-Marc does not consider Hop Tests as an assessment test. Hop tests were not found to be used in preseason as reference values prior to possible future injuries, data which could be beneficial for a safe return to sport. Harris J, Abrams G, Bach B, Williams D, Heidloff D, Bush-Joseph C, Verma N, Forsythe B, Cole B. Return to Sport After ACL Reconstruction. ORTHOPEDICS. 2014; 37: e103-e108. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy. 2011 Dec;27(12):1697-705. Thomeé R, Kaplan Y, Kvist J, Myklebust G, Risberg MA, Theisen D, Tsepis E, Werner S, Wondrasch B, Witvrouw E. Muscle strength and hop performance criteria prior to return to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011 Nov;19(11):1798-805. Bolgla LA, Keskula DR. Reliability of lower extremity functional performance tests. J Orthop Sports Phys Ther. 1997 Sep;26(3):138-42. Wellsandt E, Failla MJ, Snyder-Mackler L. Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther. 2017 Mar 29:1-18. F-MARC. Football Medicine Manual. 2nd Edition. Available from: http://f-marc.com . 2017.

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