Return to Sport after ACL Reconstruction and Other Knee Operations (eBook)

Preface 5
Contents 8
Contributors 11
Abbreviations 15
Part I: Problems and Barriers for Successful Return to Sport 19
1: Advantages and Potential Consequences of Return to Sport After ACL Reconstruction: Quality of Life, Reinjury Rates, and Knee Osteoarthritis 20
1.1 Introduction 20
1.2 Quality of Life and Patient Satisfaction: Correlation with Return to Sport 21
1.3 Reinjury Rates After ACL Reconstruction 22
1.4 Factors Involved in the Development of Knee Osteoarthritis After ACL Surgery 26
References 33
2: Common Symptom, Psychological, and Psychosocial Barriers to Return to Sport 41
2.1 Common Physical Barriers 41
2.2 Common Psychological and Psychosocial Barriers 45
2.2.1 Fear of Reinjury and Reinjury Anxiety 45
2.2.2 Self-Efficacy 48
2.2.3 Locus of Control 48
2.3 Conclusions 49
References 49
3: The Arthritis Barrier: Long-Term Effects of ACL Trauma on Knee Joint Health 52
3.1 Epidemiology of Post-Traumatic Osteoarthritis Following ACL Trauma 52
3.2 Effect of Sport on PTOA Following ACL Trauma 53
3.3 Effect of ACL Injury and Concomitant Articular Cartilage Injury on PTOA 54
3.4 Effect of ACL Injury and Post-Traumatic Bone Marrow Lesions on PTOA 55
3.5 Effect of ACL Disruption and Concomitant Meniscal Injury on PTOA 56
3.6 Effect of Surgical Versus Nonsurgical Treatment of ACL Injury on PTOA 57
3.7 Effect of Timing of ACL Reconstruction Surgery on PTOA 58
3.8 Effect of ACL Graft Material on PTOA 58
3.9 Effect of ACL Trauma on Patellofemoral and Tibiofemoral PTOA 59
3.10 Return to Sport Considerations for Athletes 59
3.11 Limitations of the Current Literature 60
References 61
Part II: Return to Sport: Whose Decision Is It? 66
4: Return to Sport Decision-Based Models 67
4.1 Introduction 67
4.2 Overall Athlete Care 68
4.3 StARRT Framework for RTS Decision-Making 70
4.3.1 Step 1: Tissue Health 71
4.3.2 Step 2: Tissue Stresses 71
4.3.3 Step 3: Risk Tolerance Modifiers 71
4.4 A Concrete Example in Applying the StARRT Framework 72
4.4.1 Multiple Outcomes 73
4.4.2 From StARRT to Decision-Tree Analysis 74
4.5 The Athlete’s Best Interests? 74
4.6 Which Stakeholder Should Be the Decision-Maker? 75
4.6.1 Protecting the Athlete with a Multidisciplinary Approach? 77
4.7 Summary 78
References 78
5: Role of the Team Physician, Orthopedic Surgeon, and Rehabilitation Specialists 80
5.1 Introduction 80
5.2 Preoperative Phase 80
5.3 Early Postoperative Phase 83
5.4 Late Postoperative Phase 85
5.5 RTS Phase 86
5.6 Summary 90
References 90
6: Return to Sport After Primary ACL Reconstruction in Amateur, Children, and Elite Athletes: Feasibility and Reinjury Concerns 92
6.1 Introduction 92
6.2 Amateur Athletes 94
6.2.1 Return to Sport: Rates and Influential Factors 94
6.2.2 Reinjuries: Rates and Significant Factors 105
6.2.3 Published Criteria for Release to Unrestricted Activities 105
6.2.4 Conclusions and Recommendations 105
6.3 Children and Adolescent Athletes 108
6.3.1 Return to Sport: Rates and Influential Factors 108
6.3.2 Reinjuries: Rates and Significant Factors 111
6.3.3 Published Criteria for Release to Unrestricted Activities 115
6.3.4 Conclusions and Recommendations 115
6.4 Elite Collegiate and Professional Athletes 116
6.4.1 Return to Sport: Rates and Influential Factors 116
6.4.2 Reinjuries: Rates and Significant Factors 120
6.4.3 Published Criteria for Release to Unrestricted Activities 122
6.4.4 Conclusions and Recommendations 122
6.5 Future Concerns 123
References 124
Part III: Spectrum of Optimal Treatment of ACL Injuries 132
7: What Is the Scientific Basis for Knee Ligament Healing and Maturation to Restore Biomechanical Properties and a Return to Sport? 133
7.1 ACL Anatomy: Native Tendon-Bone Insertion 133
7.2 Why Does the Injured ACL Not Heal? 133
7.3 Historical Perspective on the Concept of Ligamentization 134
7.4 Biological Healing of the Graft 135
7.4.1 Phases of Intraarticular Healing 135
7.4.1.1 Early Graft Healing: Graft Necrosis and Early Inflammation 135
7.4.1.2 Proliferation and Recellularization 136
7.4.1.3 Revascularization 137
7.4.1.4 Ligamentization 138
7.5 Tunnel Healing 141
7.5.1 Bone Quality Composition 144
7.5.2 Graft Fixation Technique 144
7.5.3 Tunnel-Tendon Gap Size 145
7.5.4 Tunnel Length 145
7.5.5 Mechanical Stress and Graft Healing 145
7.5.6 Graft Tension 146
7.6 Allograft Healing 147
7.7 Healing Challenges in ACL Reconstruction 148
7.8 Modes of Failure Based on Point of Time. 148
7.9 Biological Techniques of Enhancing Tendon-Bone Healing 149
7.9.1 Growth Factors and Bone Proteins 149
7.9.2 Matrix Metalloproteinases and Tissue Inhibitors of Metalloproteinases 150
7.9.3 Cellular and Stem Cell Adjuncts 151
7.9.4 The Inflammatory Response 151
7.10 Assessing Graft Maturation and Healing through Imaging 153
7.10.1 Radiographs 153
7.10.2 Computed Tomography 153
7.10.3 Magnetic Resonance Imaging 153
7.11 Future Directions of ACL Healing: ACL Preservation and Bioenhanced Repair 155
7.11.1 Bridge-Enhanced Anterior Cruciate Ligament Repair 156
7.11.2 Arthroscopic Primary ACL Repair with Suture Augmentation 156
7.11.3 Dynamic Intraligamentary Stabilization 157
7.12 Conclusion 157
References 158
8: Preoperative Rehabilitation: Basic Principles 168
8.1 Introduction 168
8.2 Issues to Treat and Resolve Before ACL Reconstruction 170
8.2.1 Hemarthrosis and Knee Joint Effusion 170
8.2.2 Limitations in Knee Motion 171
8.2.3 Loss of Muscle Strength 172
8.2.4 Impairments in Neuromuscular Function 173
8.3 Clinical Studies 177
References 180
9: Extended Preoperative Rehabilitation: Does It Influence Return to Sport After Surgery? 184
9.1 Introduction 184
9.2 Background 185
9.2.1 Preoperative Milestones 185
9.2.2 Importance of Quadriceps Strength 185
9.2.3 Evidence for Preoperative Rehabilitation 185
9.3 Evidence-Based Preoperative Rehabilitation Interventions 186
9.3.1 Perturbation Training 186
9.3.2 Progressive Strength Training 186
9.3.3 Agility and Plyometric Training 186
9.4 Postoperative Criterion-Based Rehabilitation 188
9.5 Return to Sport Timeline and Criteria 197
9.6 Outcomes After Extended Preoperative Rehabilitation 199
9.7 Summary 200
9.8 Critical Points 200
References 200
10: Intraoperative Considerations Crucial for a Successful Outcome 203
10.1 Introduction 203
10.1.1 Indications for ACL Reconstruction 203
10.1.2 Contraindications for ACL Reconstruction 204
10.1.3 Preoperative Planning 204
10.1.4 ACL Graft Selection 205
10.1.4.1 Critical Points 206
10.2 Intraoperative Evaluation 206
10.3 Graft Harvest 206
10.3.1 B-PT-B Autograft 206
10.3.2 Graft Harvest: STG Autograft 207
10.3.3 Graft Harvest: QT-PB Autograft 209
10.4 ACL Anatomic Reconstruction 211
10.4.1 ACL Anatomy and Function Issues 211
10.4.2 Recommended Location and Placement of Tibial Tunnel 213
10.4.3 Recommended Location and Placement of Femoral Tunnel 214
10.4.4 Graft Tunnel Passage, Conditioning, and Fixation 216
10.4.5 Technique Using STG Graft 219
10.4.5.1 Critical Points 222
10.5 Authors’ ACL Reconstruction Clinical Studies 222
10.6 Treatment of Meniscus Tears 222
References 228
11: Early Postoperative Rehabilitation to Avoid Complications and Prepare for Return to Sport Training 232
11.1 Introduction 232
11.2 Clinical Concepts 234
11.2.1 Control Knee Joint Effusion 234
11.2.2 Immediate Knee Motion and Early Weight-Bearing 234
11.2.3 Electrical Muscle Stimulation and Biofeedback 234
11.2.4 Muscle Loss After ACL Reconstruction 235
11.2.5 Regaining Strength: Patellofemoral Joint Protection 235
11.2.6 Open and Closed Kinetic Chain Exercises: Which Are Safe Early Postoperatively? 236
11.2.7 Other Muscle Training Options 238
11.2.8 Early Restoration of Neuromuscular Function 240
11.3 Recognition of Major Complications 241
11.4 Protocol for Primary ACL Bone-Patellar Tendon-Bone Autogenous Reconstruction: Early Return to Strenuous Activities 248
11.5 Protocol with Delayed Parameters for Revision ACL Reconstruction, Multi-ligament Reconstruction, Allografts, and Complex Knees 255
References 260
12: Early Postoperative Role of Blood Flow Restriction Therapy to Avoid Muscle Atrophy 270
12.1 Introduction 270
12.2 Disuse Muscle Atrophy 270
12.3 Impact on Strength 271
12.4 Arthrogenic Inhibition 271
12.5 Blood Flow Restriction Training (BFRT) and Usage in ACL Rehabilitation 272
12.5.1 Phase 1: Prehabilitation with BFRT 274
12.5.2 Phase 2: Early Postoperative with BFRT 275
12.5.3 Phase 3: Postoperative Ambulation with BFRT 276
12.5.4 Phase 4: Low-Load Resistance Training with BFRT 276
12.5.5 Phase 5: Heavy-Load Resistance Training with Low-Load BFRT 277
12.6 Safety Considerations 277
12.7 Conclusion 278
References 278
Part IV: Return to Sport Advanced Training Concepts 284
13: Current Concepts of Plyometric Exercises for the Lower Extremity 285
13.1 Introduction 285
13.2 History of Plyometrics 286
13.3 Definition of Plyometrics 286
13.4 Phases of Plyometrics 287
13.4.1 Eccentric Prestretch Loading Phase 287
13.4.2 Transition, Amortization (Coupling, Rebound) Phase 287
13.4.3 Concentric Unloading Shortening Phase 288
13.5 Scientific Foundation of Plyometrics 289
13.5.1 Neuromusculoskeletal Adaptations to Plyometric Training 289
13.5.2 Bone 289
13.5.3 Tendon 289
13.5.4 Muscle [100] 290
13.5.5 Neural 290
13.6 Examples of Plyometrics in Athletics 290
13.7 Contraindications for Plyometrics of the Knee 291
13.8 Theoretical Training Benefits of Plyometric Exercises for the Knee 291
13.9 Criterion-Based Clinical Guidelines for Beginning a Plyometric Program 291
13.10 Designing a Plyometric Program for the Knee 293
13.10.1 Periodization Program 294
13.10.2 Scientific Foundation for the Application of Plyometrics 295
13.10.3 Specific Principles and Concepts: Components of a Plyometric Training Program 295
13.10.4 Components for Progression of a Plyometric Training Program 295
13.10.5 Plyometric Techniques 295
13.10.6 Examples of Lower Extremity Plyometric Exercises 297
13.11 Functional Testing Algorithm (FTA) for Clinical Decision-Making for Return to Activity 307
13.12 Summary 307
References 307
14: Running, Agility, and Sportsmetrics Training 313
14.1 Introduction 313
14.2 Running and Agility Program 314
14.3 Basic Plyometric Training Program 314
14.4 Sportsmetrics Neuromuscular Retraining 315
14.4.1 Dynamic Warm-Up 316
14.4.1.1 Toe Walk 317
14.4.1.2 Heel Walk 317
14.4.1.3 Straight Leg March 317
14.4.1.4 Leg Cradle 318
14.4.1.5 Dog and Bush (Hip Rotator) Walk 318
14.4.1.6 High Knee Skip 318
14.4.1.7 High Knees 318
14.4.1.8 Glut Kicks 318
14.4.1.9 Stride Out 319
14.4.1.10 All-Out Sprint 319
14.4.2 Plyometrics/Jump Training 319
14.4.2.1 Wall Jump 321
14.4.2.2 Tuck Jump 321
14.4.2.3 Squat Jump 322
14.4.2.4 Barrier Jump Side-to-Side 322
14.4.2.5 Barrier Jump Forward–Backward 322
14.4.2.6 180° Jump 322
14.4.2.7 Broad Jump 323
14.4.2.8 Bounding in Place 324
14.4.2.9 Jump, Jump, Jump, Vertical Jump 324
14.4.2.10 Barrier Hop Side-to-Side, Single Leg 324
14.4.2.11 Barrier Hop Forward–Backward, Single Leg 324
14.4.2.12 Scissor Jump 324
14.4.2.13 Single-leg Hop 325
14.4.2.14 Bounding for Distance 326
14.4.2.15 Jump Up, Down, 180°, Vertical 326
14.4.2.16 Mattress Jump Side-to-Side 329
14.4.2.17 Mattress Jump Forward–Backward 329
14.4.2.18 Hop, Hop, Hop, Stick 329
14.4.2.19 Jump into Bounding 329
14.4.3 Strength Training 330
14.4.3.1 Mini-Squats with Resistance Band 331
14.4.3.2 Walking Lunges Forward 332
14.4.3.3 Prone Hamstrings with Partner Resistance 332
14.4.3.4 Supine Hamstring Bridge 332
14.4.3.5 Bridge with Alternating Leg Hamstring Glide 332
14.4.3.6 Bridge with Double-leg Hamstring Glide 333
14.4.3.7 Arm Swing with Resistance Band 333
14.4.3.8 Superman (Alternating Arms/Legs) 333
14.4.3.9 Abdominals (Russian Twists) 333
14.4.3.10 Abdominals (Plank) 334
14.4.3.11 Abdominals (Bicycle Kicks) 334
14.4.3.12 Hip Flexor Resistance Band Kicking 335
14.4.3.13 Steamboats (Hip Flexion) 335
14.4.3.14 Hip Abductor Resistance Band kicking 336
14.4.3.15 Lateral Walking with Resistance Band 337
14.4.4 Flexibility 338
14.4.4.1 Hamstrings 338
14.4.4.2 Iliotibial Band 338
14.4.4.3 Quadriceps 339
14.4.4.4 Hip Flexor 340
14.4.4.5 Gastrocnemius 340
14.4.4.6 Soleus 341
14.4.4.7 Deltoid 341
14.4.4.8 Triceps, Latissimus Dorsi 341
14.4.4.9 Pectoralis, Biceps 341
14.4.4.10 Low Back 341
14.5 Release to Unrestricted Sports Activities 342
References 345
15: Key Vital Steps in Returning Athletes to Sports Following ACL Surgery 349
15.1 Introduction 349
15.2 Return to Sport: 10 Critical Steps for Success 350
15.2.1 Key Point 1: Restore Full Passive Knee Motion and Patellar Mobility 350
15.2.2 Key Point 2: Normalize Quadriceps Strength 352
15.2.3 Key Point 3: Restoration of Neuromuscular Control and Dynamic Functional Stability 353
15.2.4 Key Point 4: Retrain the Ability to Change Direction with Skill 355
15.2.5 Key Point 5: Restore Lateral Hip Strength 355
15.2.6 Key Point 6: Knee Control Must Be Provided from Both Above and Below 356
15.2.7 Key Point 7: Improve Hamstrings Activation and Strength 356
15.2.8 Key Point 8: Teach Proper Landing Technique 357
15.2.9 Key Point 9: Teach Proper Running and Cutting Technique 359
15.2.10 Key Point 10: Use Objective Criteria Fulfillment for Progression Back to Sport 360
15.3 Conclusions 363
References 364
16: Neuroscience Principles for ACL Rehabilitation and Reinjury Risk Reduction 367
16.1 Anterior Cruciate Ligament Injury 367
16.2 Limitations of the Classic Structural-Mechanical Model 368
16.3 Neuromuscular Control 369
16.4 Neuromechanical Principles of Performance and Injury Risk 370
16.5 ACL Specific Neurological Adaptations 372
16.6 Neuroplasticity in Sport Rehabilitation 373
16.7 ACL Injury Induced Sensory-Visual-Motor Processing Compensations 375
16.8 Use of Neuromechanical Principles in Clinical Settings 377
16.9 Case Examples 380
16.9.1 Case 1 380
16.9.2 Case 2 380
References 381
17: Return to Sport for Soccer and Basketball 390
17.1 Introduction 390
17.2 Techniques for Running, Agility, and Reaction Drills 391
17.3 Soccer (Table 17.1) 392
17.3.1 Agility and Reaction Drills 392
17.3.1.1 Serpentine Run 392
17.3.1.2 Wheel Drill: Listen to Instructor 392
17.3.1.3 Shuttle Run 392
17.3.1.4 Sprint-Stop Feet-Listen to Instructor 395
17.3.1.5 Sprint-Quick Feet-Listen to Instructor 395
17.3.1.6 Square Drill 395
17.3.1.7 Nebraska Agility Drill 396
17.3.1.8 Reaction Drill-Watch Instructor Point 397
17.3.1.9 Reaction Mirror Drill-Partner Pressing 397
17.3.1.10 Illinois Drill 397
17.3.1.11 T-Drill: 5–10-5 397
17.3.1.12 Advanced Wheel Drill: Listen to Instructor 398
17.3.2 Acceleration, Speed, and Endurance Drills 398
17.3.2.1 Partner Push-Offs 398
17.3.2.2 Acceleration with Band 399
17.3.2.3 Sprint with Ground Touches-Backpedal 399
17.3.2.4 ¼ Eagle Sprint-Backpedal 399
17.3.2.5 Box Drill, Sprint-90°-Backpedal 399
17.3.2.6 Sprint-180°-Backpedal 399
17.3.2.7 Jingle Jangle 400
17.3.2.8 Sprint-360°-Sprint, Jog Back 400
17.3.3 Ladders, Additional Jump Drills 400
17.3.3.1 Ladder: Up-Up and Back-Back 400
17.3.3.2 Ladder: Toe Touches 400
17.3.3.3 Ladder: Outside Foot In 400
17.3.3.4 Ladder: In-In, Out-Out 402
17.3.3.5 Ladder: 1 Foot Forward, 1 Foot Backward 402
17.3.3.6 Dot Drill: Double-Leg Jumps 402
17.3.3.7 Dot Drill: Split-Leg Jumps 402
17.3.3.8 Dot Drill: 180° Split-Leg Jumps 404
17.3.3.9 Dot Drill: Single-Leg Hops 404
17.3.3.10 Dot Drill: Combo All Jumps 405
17.4 Basketball (Table 17.2) 405
17.4.1 Agility and Reaction Drills 405
17.4.1.1 Shuttle Drill 405
17.4.1.2 Maze Drill 407
17.4.1.3 Tip Drill 407
17.4.1.4 Figure 4 Drill 407
17.4.1.5 Square Drill 408
17.4.1.6 4 Dot Drill, Ladder 408
17.4.1.7 Defensive Slides 408
17.4.1.8 Shoot and Sprint 408
17.4.1.9 Irish D Drill 408
17.4.1.10 T-Drill: 5–10-5 410
17.4.1.11 Kill the Grass Drill 410
17.4.2 Acceleration, Speed, and Endurance Drills 410
17.4.2.1 Mountain Climbers 410
17.4.2.2 Sprint-Backpedal 411
17.4.2.3 Suicides 411
17.4.2.4 Suicides Forward-Backward 411
17.4.2.5 ¼ Eagle Sprint-Backpedal 411
17.4.2.6 Suicides: Defensive Slides 411
17.4.2.7 Sprint with Ground Touches 412
17.4.2.8 Full-Court Relay 412
17.4.2.9 Sprint-180°-Backpedal 412
17.4.2.10 Sprint-Quick Feet-Backpedal 412
17.4.2.11 Sprint-360°-Backpedal 412
17.4.2.12 Power Rebounds Relay 412
17.4.3 Ladders, Quick Feet, Additional Jump Drills 413
17.4.3.1 Ladder: High Knees 413
17.4.3.2 Ladder: Up-Up/Back-Back 413
17.4.3.3 Ladder: Outside Foot In 413
17.4.3.4 Ladder: In-In, Out-Out 414
17.4.3.5 Ladder: Scissors 414
17.4.3.6 Ladder: Icky Shuffle 414
17.4.3.7 High Knee Ball Toss Over Barrier 414
17.4.3.8 Double High Knee Ball Toss Over Barrier 415
17.4.3.9 Bleacher Jumps 415
17.4.3.10 Single-Leg Squat Jumps 415
17.4.3.11 180° Scissor Jumps 415
17.4.3.12 Dot Drills 415
17.5 Field Test Recommendations 416
17.5.1 Soccer Players 416
17.5.2 Basketball Players 418
17.6 Results of Programs 420
17.6.1 Sportsmetrics Soccer 420
17.6.2 Sportsmetrics Basketball 421
References 421
18: Return to Sport for Tennis 427
18.1 Introduction 427
18.2 Techniques for Running, Agility, and Reaction Drills 432
18.3 Agility and Reaction Drills 434
18.3.1 Shadow Swing Baseline, Forehand and Backhand 434
18.3.2 Alternating Short/Deep Balls, Forehand and Backhand 434
18.3.3 Resistance Belt Forehand and Backhand 435
18.3.4 Rapid Drop Feed Forehand and Backhand 435
18.3.5 Forehand and Backhand Reaction, Facing Net 436
18.3.6 Forehand and Backhand Reaction, Facing Fence 436
18.3.7 Rapid Return Serve Feeds Forehand and Backhand 437
18.3.8 Ladder Up-Up, Back-Back, Sprint to Groundstroke, Sprint to Volley, Forehand and Backhand 437
18.4 Acceleration, Speed, and Endurance Drills 437
18.4.1 Suicides, 1-Court 437
18.4.2 Suicides, 2-Court 438
18.4.3 Net Zigzag 438
18.4.4 Forehand and Backhand Wide Continuous Hitting 438
18.4.5 Baseline Random Feed Forehand and Backhand 440
18.4.6 Sprint-Quick Feet-Listen to Instructor 440
18.5 Ladders, Quick Feet, Additional Jump Drills 441
18.5.1 Ladder: Up-Up, Back-Back, Sprint to Cone, Backpedal 441
18.5.2 Backward Broad Jump 441
18.5.3 Pattern Jumps 441
18.6 On-the-Court Strength Training 442
18.6.1 Medicine Ball Forehand, Backhand, Overhead, Between Legs 442
18.6.2 ETCH-Swing Forehand, Backhand, Serve 443
18.6.3 Backward Lunge 443
18.6.4 Twisting Lunge with Medicine Ball 443
18.6.5 Toe Walking 443
18.6.6 Wall Push-Ups 443
18.6.7 Wall Sits 445
18.6.8 TheraBand Crab Walking (Lateral Lunges) 446
18.6.9 Ball-Wall Exercises 446
18.7 Lower Extremity Power and Dynamic Balance Tests 446
18.7.1 Single-Leg Hop 446
18.7.2 Single-Leg Triple Crossover Hop 448
18.7.3 1-Repetition Maximum Leg Press 448
18.7.4 Countermovement Vertical Jump 448
18.8 Upper Body Strength and Power Tests 450
18.8.1 Sitting Chest Pass 450
18.8.2 Standing Medicine Ball Toss: Chest Pass, Forehand Backhand, Overhead 450
18.8.3 1-Repetition Maximum Bench Press 452
18.9 Abdominal Strength and Endurance Tests 452
18.9.1 Sit-Up Test 452
18.9.2 Abdominal Endurance Test 452
18.10 Speed and Agility Tests 452
18.10.1 1-Court Suicide 452
18.10.2 Baseline Forehand and Backhand Tests 452
18.10.3 Service Box Test 454
18.10.4 10-M and 20-M Sprint 454
18.11 Aerobic Fitness Tests 455
18.11.1 Multistage Fitness Test 455
18.11.2 Intermittent Recovery: Yo-Yo Test Level 1 and Level 2 455
18.12 Results of Program 456
References 457
Part V: Objective Testing 462
19: The Physician’s Comprehensive Examination for Return to Sport 463
19.1 Introduction 463
19.2 Radiographs 468
19.3 Range of Knee Motion, Muscle Strength, and Gait 470
19.4 Patellofemoral Examination 470
19.5 Meniscus Tests 474
19.6 Knee Ligament Tests 474
19.6.1 Anterior Cruciate Ligament 474
19.6.2 Posterior Cruciate Ligament 477
19.6.3 Medial Collateral Ligament 477
19.6.4 Lateral Collateral Ligament and Posterolateral Structures 478
19.7 Determination of Articular Cartilage Damage 479
19.8 Diagnosis of Complex Regional Pain Syndrome 480
References 481
20: Neuromuscular Function, Agility, and Aerobic Testing 485
20.1 Introduction 485
20.2 Cost-Effective Neuro­muscular Function Tests 486
20.2.1 Video Drop-Jump Screening Test 486
20.2.2 Video Plant and Cut Test 489
20.3 Agility Tests 490
20.3.1 T-test 490
20.3.2 Pro-Agility Test 490
20.3.3 Illinois Agility Test 492
20.3.4 505 Test 492
20.4 Aerobic Tests 492
20.4.1 Estimated Maximal Oxygen Uptake: Multistage Fitness Test 492
20.4.2 Intermittent Recovery: Yo-Yo Test Level 1 and Level 2 499
References 501
21: Muscle Strength and Dynamic Balance Stability Tests 508
21.1 Introduction 508
21.2 Muscle Strength Tests 508
21.2.1 Isokinetic Testing 508
21.2.2 Isometric Testing Using an Isokinetic Dynamometer 510
21.2.3 Isometric Testing with a Hand-Held Dynamometer 513
21.2.4 1-Repetition Maximum Leg Press 514
21.2.5 Anaerobic Power: Vertical Jump 515
21.2.6 Abdominal Strength and Endurance 515
21.2.7 Core Stability 515
21.3 Single-Leg Dynamic Balance Stability Tests 517
21.3.1 Hop Tests 517
21.3.1.1 Single Hop 517
21.3.1.2 Triple Hop 519
21.3.1.3 Triple Crossover Hop 519
21.3.1.4 Timed 6-M Hop 519
21.3.2 Star Excursion Balance Test 520
21.3.3 Y-Balance Test 520
21.3.4 Squat Test 522
21.3.5 Timed Step-Down Test 522
References 524
22: Neurocognitive Testing 532
22.1 Introduction 532
22.2 Neurocognitive Function and ACL Injury 532
22.3 Computerized Neurocognitive Tests 535
22.3.1 Factors and Limitations Affecting Neurocognitive Assessment Tools 536
22.4 Types of NCATs 537
22.4.1 Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) 537
22.4.2 Automated Neuropsychological Assessment Metrics (ANAM) 538
22.4.3 Axon Sports Computerized Cognitive Assessment Tool (CogSport/CogState) 538
22.4.4 Defense Automated Neurobehavioral Assessment (DANA) 539
22.4.5 National Institutes of Health Toolbox Cognition Battery (NIHTB-CB) 539
22.5 Future Directions: Executive Function Training? 540
References 540
Part VI: Psychological Readiness 544
23: Validated Questionnaires to Measure Return to Sport and Psychological Factors 545
23.1 Introduction 545
23.2 Sports Activity Scales 545
23.2.1 Cincinnati Sports Activity Scale 545
23.2.2 Tegner Activity Scale 547
23.2.3 Marx Sports Activity Scale 549
23.2.4 IKDC Sports Scale 550
23.3 Psychological Questionnaires (Table 23.7) 550
23.3.1 ACL-Return to Sport After Injury (ACL-RSI) Scale 550
23.3.2 Tampa Scale for Kinesiophobia (TSK) [41, 42] 552
23.3.3 Knee Self-Efficacy Scale (K-SES) [57] 552
23.3.4 Injury-Psychological Readiness to Return to Sport Scale (I-PRRS) [61] 553
23.3.5 Reinjury Anxiety Inventory (RIA) [63] 553
23.3.6 Quick Inventory of Depressive Symptomatology (QIDS) [64] 555
23.3.7 Multidimensional Health Locus of Control Scale [68] 557
23.3.8 State-Trait Anxiety Inventory [74] 557
23.4 Conclusions 557
References 560
24: Identification and Management of Psychosocial Issues in the Athlete for Return to Sport 564
24.1 Introduction 564
24.2 Psychosocial Models for Return to Sport 564
24.3 Cognitive Factors 565
24.3.1 Expectation of Recovery 565
24.3.2 Motivation to Return to Sport 566
24.3.3 Self-Efficacy 567
24.4 Emotional Factors 567
24.4.1 Mood and Anxiety 567
24.4.2 Fear of Movement or Reinjury 568
24.5 Psychological Readiness 568
24.6 Behavioral Factors 568
24.6.1 Rehabilitation Adherence 568
24.7 Management Strategies for Addressing Psychosocial Factors 569
24.7.1 Psychosocial Strategies from Randomized Trials 569
24.7.2 Psychosocial Strategies from Case Studies 570
24.7.3 Other Psychosocial Strategies 570
24.8 Future Directions for Research 571
24.9 Conclusion 571
References 571
Part VII: Other Knee Operations 575
25: Return to Sport After ACL Revision Reconstruction: Is It Advisable? 576
25.1 Introduction 576
25.2 Return to Sport: Rates and Influential Factors from Clinical Studies 577
25.3 Reinjury/Failure Rates and Significant Factors 584
25.4 Criteria for Return to Sports 584
25.5 Multiple-Revision ACL Reconstruction Studies 585
25.6 Conclusions and Future Study Considerations 586
References 588
26: Return-to-Sport Considerations in the Pre-Adolescent Athlete 591
26.1 Introduction 591
26.2 Preoperative Considerations 591
26.2.1 Skeletal vs. Bone Age 591
26.2.2 Standing Alignment 592
26.2.3 Graft Selection 592
26.2.4 Partial ACL Tears 592
26.3 Surgical Techniques for Skeletally Immature Patients 592
26.3.1 Micheli/Kocher Technique 592
26.3.2 Anderson Technique 593
26.4 Rehabilitation Considerations in the Child/Pre-Adolescent Patient 593
26.5 Return-to-Sport Functional Testing 597
26.6 Functional Knee Bracing 597
26.7 Psychological Readiness 598
26.8 Factors Affecting Rate of Reinjury 599
26.9 Outcomes 599
26.10 Complications in the Pre-Adolescent Patient 600
26.10.1 Growth Disturbance 600
26.10.2 Arthrofibrosis 600
26.11 Prevention 601
26.12 Summary 601
References 601
27: Return to Sport After Meniscus Operations: Meniscectomy, Repair, and Transplantation 604
27.1 Introduction 604
27.1.1 Functions of the Menisci and the Importance of Preservation 604
27.1.2 Options for Treatment of Meniscus Tears in Athletes 606
27.2 Return to Sport After Meniscectomy 609
27.2.1 RTS Rates and Influential Factors 613
27.2.2 Rehabilitation Criteria for RTS 614
27.2.3 Progression of Knee Osteoarthritis 614
27.3 Return to Sport After Meniscus Repair 614
27.3.1 RTS Rates and Influential Factors 614
27.3.2 Rehabilitation Criteria for RTS 618
27.3.3 Failure Rates of Meniscus Repairs 618
27.3.4 Progression of Knee Osteoarthritis 620
27.4 Return to Sport After Meniscus Transplantation 620
27.4.1 RTS Rates and Influential Factors 620
27.4.2 Rehabilitation Criteria for RTS 623
27.4.3 Failure Rates of Meniscus Transplants 623
27.4.4 Progression of Knee Osteoarthritis 624
27.5 Conclusions and Comments 624
References 624
28: Return to Sport After Patellofemoral Realignment and Stabilization Procedures 632
28.1 Introduction 632
28.2 Return to Sport After MPFL Reconstruction 636
28.3 Return to Sport After Patellar Realignment Procedures 636
28.4 Failure Rates 645
28.5 Advances in Operative Techniques for RTS 646
28.6 Postoperative Rehabilitation Concepts 646
References 649
29: Return to Sport After Cartilage Procedures 655
29.1 Introduction 655
29.2 Microfracture 656
29.3 MACI 658
29.4 Osteochondral Autograft Transplantation 660
29.5 Osteochondral Allograft Transplantation 662
29.6 Rehabilitation Protocol 664
29.7 Discussion 664
29.8 Conclusion 665
References 665
30: Return to Sport After Unicondylar, Patellofemoral, and Total Knee Arthroplasty 669
30.1 Introduction 669
30.2 RTS After Unicondylar Knee Arthroplasty 671
30.2.1 Medial UKA 671
30.2.2 Lateral UKA 674
30.3 RTS After Patellofemoral Arthroplasty 674
30.4 RTS After Total Knee Arthroplasty 676
30.5 Rehabilitation Principles for RTS After Partial or Total Knee Arthroplasty 682
30.5.1 Criteria for Return to Recreational Sports 687
30.6 Conclusions and Comments 688
References 689
Index 693