Publications by authors named "Jacob J Capin"

20 Publications

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Knee cartilage T relaxation times 3 months after ACL reconstruction are associated with knee gait variables linked to knee osteoarthritis.

J Orthop Res 2021 Mar 30. Epub 2021 Mar 30.

Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA.

Osteoarthritis development after ACL reconstruction (ACLR) is not well understood. Investigators have examined associations between knee biomechanical alterations and quantitative MRI (qMRI) variables, reflective of cartilage health, 12-60 months following ACLR; however, none have done so early after surgery. As part of an exploratory study, 45 individuals (age, 23 ± 7 years) underwent motion analysis during walking and qMRI 3 months after ACLR. For each limb, peak knee adduction moment (pKAM) and peak knee flexion moment (pKFM) were determined using inverse dynamics and peak medial compartment force was calculated using a neuromusculoskeletal model. T relaxation times in the medial compartment and linear regressions were used to determine the associations between gait variables and deep and superficial cartilage T relaxation times in six regions. pKAM was positively associated with deep layer T relaxation times within the femoral central and posterior regions when examined in the involved limb and from an interlimb difference perspective (involved limb - uninvolved limb). After adjusting for age, the association between interlimb difference of pKAM and interlimb difference of deep layer T relaxation times in the tibial central region became significant (p = .043). Interlimb difference of pKFM was negatively associated with interlimb difference of deep layer T relaxation times within the femoral central and posterior regions. These associations suggest that degenerative pathways leading to osteoarthritis may be detectable as early as 3 months after reconstruction. Preventative therapeutic techniques may need to be employed early in the rehabilitation process to prevent cartilage degradation.
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http://dx.doi.org/10.1002/jor.25043DOI Listing
March 2021

Patients Walking Faster After Anterior Cruciate Ligament Reconstruction Have More Gait Asymmetry.

Int J Sports Phys Ther 2021 Feb 1;16(1):169-176. Epub 2021 Feb 1.

University of Delaware.

Background: Gait asymmetries after anterior cruciate ligament reconstruction (ACLR) may lead to radiographic knee osteoarthritis. Slower walking speeds have been associated with biomarkers suggesting cartilage breakdown. The relationship between walking speed and gait symmetry after ACLR is unknown.

Hypothesis/purpose: To determine the relationship between self-selected walking speeds and gait symmetry in athletes after primary, unilateral ACLR.

Study Design: Secondary analysis of a clinical trial.

Methods: Athletes 24±8 weeks after primary ACLR walked at self-selected speeds as kinematics, kinetics, and electromyography data were collected. An EMG-driven musculoskeletal model was used to calculate peak medial compartment contact force (pMCCF). Variables of interest were peak knee flexion moment (pKFM) and angle (pKFA), knee flexion and extension (KEE) excursions, peak knee adduction moment (pKAM), and pMCCF. Univariate correlations were run for walking speed and each variable in the ACLR knee, contralateral knee, and interlimb difference (ILD).

Results: Weak to moderate positive correlations were observed for walking speed and all variables of interest in the contralateral knee (Pearson's r=.301-.505, p≤0.01). In the ACLR knee, weak positive correlations were observed for only pKFM (r=.280, p=0.02) and pKFA (r=.263, p=0.03). Weak negative correlations were found for ILDs in pKFM (r=-0.248, p=0.04), KEE (r=-.260, p=0.03), pKAM (r=-.323, p<0.01), and pMCCF (r=-.286, p=0.02).

Conclusion: Those who walk faster after ACLR have more asymmetries, which are associated with the development of early OA. This data suggests that interventions that solely increase walking speed may accentuate gait symmetry in athletes early after ACLR. Gait-specific, unilateral, neuromuscular interventions for the ACLR knee may be needed to target gait asymmetries after ACLR.

Level Of Evidence: III.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872452PMC
February 2021

Quadriceps Strength Symmetry Does Not Modify Gait Mechanics After Anterior Cruciate Ligament Reconstruction, Rehabilitation, and Return-to-Sport Training.

Am J Sports Med 2021 02 29;49(2):417-425. Epub 2020 Dec 29.

Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA.

Background: After anterior cruciate ligament (ACL) reconstruction (ACLR), biomechanical asymmetries during gait are highly prevalent, persistent, and linked to posttraumatic knee osteoarthritis. Quadriceps strength is an important clinical measure associated with preoperative gait asymmetries and postoperative function and is a primary criterion for return-to-sport clearance. Evidence relating symmetry in quadriceps strength with gait biomechanics is limited to preoperative and early rehabilitation time points before return-to-sport training.

Purpose/hypothesis: The purpose was to determine the relationship between symmetry in isometric quadriceps strength and gait biomechanics after return-to-sport training in athletes after ACLR. We hypothesized that as quadriceps strength symmetry increases, athletes will demonstrate more symmetric knee joint biomechanics, including tibiofemoral joint loading during gait.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: Of 79 athletes enrolled in the ACL-SPORTS Trial, 76 were participants in this study after completing postoperative rehabilitation and 10 return-to-sport training sessions (mean ± SD, 7.1 ± 2.0 months after ACLR). All participants completed biomechanical walking gait analysis and isometric quadriceps strength assessment using an electromechanical dynamometer. Quadriceps strength was calculated using a limb symmetry index (involved limb value / uninvolved limb value × 100). The biomechanical variables of interest included peak knee flexion angle, peak knee internal extension moment, sagittal plane knee excursion at weight acceptance and midstance, quadriceps muscle force at peak knee flexion angle, and peak medial compartment contact force. Spearman rank correlation (ρ) coefficients were used to determine the relationship between limb symmetry indexes in quadriceps strength and each biomechanical variable; alpha was set to .05.

Results: Of the 76 participants, 27 (35%) demonstrated asymmetries in quadriceps strength, defined by quadriceps strength symmetry <90% (n = 23) or >110% (n = 4) (range, 56.9%-131.7%). For the biomechanical variables of interest, 67% demonstrated asymmetry in peak knee flexion angle; 68% and 83% in knee excursion during weight acceptance and midstance, respectively; 74% in internal peak knee extension moment; 57% in medial compartment contact force; and 74% in quadriceps muscle force. There were no significant correlations between quadriceps strength index and limb symmetry indexes for any biomechanical variable after return-to-sport training ( > .129).

Conclusion: Among those who completed return-to-sport training after ACLR, subsequent quadriceps strength symmetry was not correlated with the persistent asymmetries in gait biomechanics. After a threshold of quadriceps strength is reached, restoring strength alone may not ameliorate gait asymmetries, and current clinical interventions and return-to-sport training may not adequately target gait.
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http://dx.doi.org/10.1177/0363546520980079DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7863565PMC
February 2021

FUNCTIONAL MEASURES DO NOT DIFFER IN LATE STAGE REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION ACCORDING TO MECHANISM OF INJURY.

Int J Sports Phys Ther 2020 Oct;15(5):744-754

Background: Anterior cruciate ligament injuries are among the most common knee injuries. Mechanism of injury is classified as contact or non-contact. The majority of anterior cruciate ligament ruptures occur through a non-contact mechanism of injury. Non-contact anterior cruciate ligament ruptures are associated with biomechanical and neuromuscular risk factors that can predispose athletes to injuries and may impact future function. Non-contact mechanism of injury may be preceded by poor dynamic knee stability and therefore those with a non-contact mechanism of injury may be prone to poor dynamic knee stability post-operatively. Understanding how mechanism of injury affects post-operative functional recovery may have clinical implications on rehabilitation.

Purpose: The purpose of this study was to determine if mechanism of injury influenced strength, functional performance, patient-reported outcome measures, and psychological outlook in athletes at four time points in the first two years following anterior cruciate ligament reconstruction.

Study Design: Secondary analysis of a clinical trial.

Methods: Seventy-nine athletes underwent functional testing at enrollment after impairment resolution. Quadriceps strength, hop testing, and patient-reported outcome measures were evaluated post-operatively at enrollment, following return-to-sport training and one year and two years after anterior cruciate ligament reconstruction. Participants were dichotomized by mechanism of injury (29 contact, 50 noncontact). Independent t-tests were used to compare differences between groups.

Results: There were no meaningful differences between contact and non-contact mechanism of injury in any variables at enrollment, post-training, one year, or two years after anterior cruciate ligament reconstruction.

Conclusion: Function did not differ according to mechanism of injury during late stage rehabilitation or one or two years after anterior cruciate ligament reconstruction.

Level Of Evidence: III.
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http://dx.doi.org/10.26603/ijspt20200744DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575151PMC
October 2020

Gait mechanics are influenced by quadriceps strength, age, and sex after total knee arthroplasty.

J Orthop Res 2021 07 2;39(7):1523-1532. Epub 2020 Nov 2.

Department of Physical Therapy, University of Delaware, Newark, Delaware, USA.

Although most patients are satisfied with outcomes after total knee arthroplasty (TKA), many retain preoperative altered gait mechanics. Identifying patient characteristics associated with gait mechanics will improve rehabilitation strategies and enhance our understanding of movement disorders. Therefore, the purpose of this study was to identify which patient characteristics are related to gait mechanics in the surgical limb during walking post-TKA. Patient characteristics included age, body mass, sex, quadriceps strength, self-reported function, and knee pain. General linear regression was used to compare patient characteristics associated with gait mechanics, after controlling for gait speed, functional capacity and time from surgery. We tested 191 patients cross-sectionally at 6-24 months after primary, unilateral TKA. Quadriceps weakness in the surgical limb was associated with less peak vertical ground reaction force (PvGRF) (β = .245, p = .044), knee extension moment (β = .283, p = .049), and knee extension excursion (β = .298, p = .038). Older age (β = .168, p = .050) was associated with less PvGRF. Quadriceps strength in the nonsurgical limb (β = -.357, p = .021) was associated with greater knee extension excursion in the surgical limb. Females with TKA (β = -.276, p = .007) had less knee flexion excursion compared to males. Faster gait speed was also associated with greater PvGRF (β = .585, p < .001), knee extensor moment (β = .481, p < .001), and knee flexion excursion (β = .318, p < .001). Statement of Clinical Significance: This study showed quadriceps weakness, slower gait speed, older age and being female were related to altered gait mechanics post-TKA. These findings will help clinicians better educate patients and develop targeted interventions for improving care in patients post-TKA.
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http://dx.doi.org/10.1002/jor.24878DOI Listing
July 2021

Sex and mechanism of injury influence knee joint loading symmetry during gait 6 months after ACLR.

J Orthop Res 2021 05 13;39(5):1123-1132. Epub 2020 Aug 13.

Department of Physical Therapy, University of Delaware, Newark, Delaware.

Early-onset knee osteoarthritis (OA) is associated with gait asymmetries after anterior cruciate ligament reconstruction (ACLR). Women have higher risks of sustaining non-contact injuries, and are more likely to present with aberrant movement patterns associated with the mechanism of injury (MOI). We hypothesized that sex and MOI would influence gait after ACLR. Seventy participants, grouped by sex and MOI, completed biomechanical testing during over-ground walking when they had full knee range of motion, trace or less knee effusion, greater than 80% quadriceps strength limb symmetry index, ability to hop on each leg without pain, and initiated running. Bilateral knee kinetics, kinematics, and joint contact forces were compared using mixed-model analysis of variance (α = .05). There was a three-way interaction effect of sex × MOI × limb for peak medial compartment contact force (P = .002), our primary outcome measure previously associated with OA development. Men with non-contact injuries walked with asymmetry characterized by underloading of the involved limb. Men with contact injuries walked with the most symmetrical loading. In women, no clear pattern emerged based on MOI. Targeting, and possibly prioritizing interventions for athletes who present with gait asymmetries after ACLR based on sex and MOI, may be necessary to optimize outcomes. Statement of Clinical Significance: Sex and MOI may influence walking mechanics, and could be considered in future interventions to target gait symmetry, as a response to interventions may vary based on differences in sex and MOI.
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http://dx.doi.org/10.1002/jor.24822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864984PMC
May 2021

A Secondary Injury Prevention Program May Decrease Contralateral Anterior Cruciate Ligament Injuries in Female Athletes: 2-Year Injury Rates in the ACL-SPORTS Randomized Controlled Trial.

J Orthop Sports Phys Ther 2020 Sep 1;50(9):523-530. Epub 2020 Aug 1.

Objective: To determine whether the addition of perturbation training to a secondary injury prevention program reduces the rate of second anterior cruciate ligament (ACL) injury compared to the prevention program alone.

Design: Single-blinded randomized controlled trial.

Methods: Thirty-nine female athletes who intended to return to cutting/pivoting sports were enrolled 3 to 9 months after primary anterior cruciate ligament reconstruction (ACLR). Athletes were randomized to receive a training program of either progressive strengthening, agility, plyometrics, and prevention (SAPP) (n = 20) or SAPP plus perturbation training (n = 19); each had 10 sessions over 5 weeks. Occurrence and side of second ACL injury were recorded for 2 years after primary ACLR.

Results: There were 9 second ACL injuries in the 2 years after ACLR. There was no statistically significant difference in rate or side of second ACL injury between the SAPP-plus-perturbation training and SAPP groups.

Conclusion: Adding perturbation training to a secondary ACL injury prevention program did not affect the rate of second ACL injury in female athletes. .
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http://dx.doi.org/10.2519/jospt.2020.9407DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484246PMC
September 2020

Athletes With Bone-Patellar Tendon-Bone Autograft for Anterior Cruciate Ligament Reconstruction Were Slower to Meet Rehabilitation Milestones and Return-to-Sport Criteria Than Athletes With Hamstring Tendon Autograft or Soft Tissue Allograft : Secondary Analysis From the ACL-SPORTS Trial.

J Orthop Sports Phys Ther 2020 May 27;50(5):259-266. Epub 2019 Nov 27.

Objective: Graft choices for athletes undergoing anterior cruciate ligament reconstruction (ACLR) include bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts and soft tissue allografts. The objective was to assess time to meet clinical milestones by graft type in athletes who completed a return-to-sport (RTS) program after ACLR.

Design: Retrospective cohort study.

Methods: Seventy-nine athletes enrolled after ACLR (allograft, n = 18; BPTB, n = 24; HT, n = 37). Time from surgery to meet (1) enrollment criteria (12 or more weeks post surgery, 80% or greater isometric quadriceps strength index, minimal effusion, and full knee range of motion), and (2) RTS criteria (90% or greater quadriceps strength index, hop testing limb symmetry, and patient-reported outcomes) was calculated. Quadriceps strength, hop performance, and patient-reported outcomes were measured before and after training, and at 1 year post surgery. Descriptive statistics, chi-square tests, and 1-way analyses of variance ( = .05) were used to analyze differences among graft types.

Results: On average, the BPTB group (28.5 ± 7.6 weeks) took longer to meet enrollment milestones than the HT (22.5 ± 7.6 weeks, = .007) and allograft (18.9 ± 5.8 weeks, <.001) groups. The BPTB group (44.7 ± 15.8 weeks) took longer from surgery to meet RTS criteria than the HT (32.5 ± 9.9 weeks, = .001) and allograft (29.3 ± 9.0 weeks, <.001) groups. After training, the quadriceps strength index was lower in the BPTB group (86.1% ± 11.4%) than it was in the HT (96.1% ± 12.9%, = .004) and allograft (96.9% ± 5.9%, = .009) groups.

Conclusion: Athletes with a BPTB autograft may take longer than athletes with an HT autograft or a soft tissue allograft to complete postoperative rehabilitation, recover quadriceps strength, and meet RTS criteria. .
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http://dx.doi.org/10.2519/jospt.2020.9111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196003PMC
May 2020

Slower Walking Speed Is Related to Early Femoral Trochlear Cartilage Degradation After ACL Reconstruction.

J Orthop Res 2020 03 18;38(3):645-652. Epub 2019 Nov 18.

Department of Mechanical Engineering, University of Delaware, Newark, Delaware.

Post-traumatic patellofemoral osteoarthritis (OA) is prevalent after anterior cruciate ligament reconstruction (ACLR) and early cartilage degradation may be especially common in the femoral trochlear cartilage. Determining the presence of and factors associated with early femoral trochlear cartilage degradation, a precursor to OA, is a critical preliminary step in identifying those at risk for patellofemoral OA development and designing interventions to combat the disease. Early cartilage degradation can be detected using quantitative magnetic resonance imaging measures, such as tissue T relaxation time. The purposes of this study were to (i) compare involved (ACLR) versus uninvolved (contralateral) femoral trochlear cartilage T relaxation times 6 months after ACLR, and (ii) determine the relationship between walking speed and walking mechanics 3 months after ACLR and femoral trochlear cartilage T relaxation times 6 months after ACLR. Twenty-six individuals (age 23 ± 7 years) after primary, unilateral ACLR participated in detailed motion analyses 3.3 ± 0.6 months after ACLR and quantitative magnetic resonance imaging 6.3 ± 0.5 months after ACLR. There were no limb differences in femoral trochlear cartilage T relaxation times. Slower walking speed was related to higher (worse) femoral trochlear cartilage T relaxation times in the involved limb (Pearson's r: -0.583, p = 0.002) and greater interlimb differences in trochlear T relaxation times (Pearson's r: -0.349, p = 0.080). Walking mechanics were weakly related to trochlear T relaxation times. Statement of clinical significance: Slower walking speed was by far the strongest predictor of worse femoral trochlear cartilage health, suggesting slow walking speed may be an early clinical indicator of future patellofemoral OA after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:645-652, 2020.
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http://dx.doi.org/10.1002/jor.24503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7028512PMC
March 2020

Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not.

Gait Posture 2019 10 27;74:87-93. Epub 2019 Aug 27.

University of Delaware, Newark, DE, USA.

Background: Partial meniscectomy dramatically increases the risk for post-traumatic, tibiofemoral osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Concomitant medial meniscus surgery influences walking biomechanics (e.g., medial tibiofemoral joint loading) early after ACLR; whether medial meniscus surgery continues to influence walking biomechanics two years after ACLR is unknown.

Research Question: Does medial meniscus treatment at the time of ACLR influence walking biomechanics two years after surgery?

Methods: This is a secondary analysis of prospectively collected data from a clinical trial (NCT01773317). Fifty-six athletes (age 24 ± 8 years) with operative reports, two-year biomechanical analyses, and no second injury prior to two-year testing participated after primary ACLR. Participants were classified by concomitant medial meniscal status: no medial meniscus involvement (n = 36), partial medial meniscectomy (n = 9), and medial meniscus repair (n = 11). Participants underwent biomechanical analyses during over-ground walking including surface electromyography; a validated musculoskeletal model estimated medial compartment tibiofemoral contact forces. Gait variables were analyzed using 3 × 2 ANOVAs with group (medial meniscus treatment) and limb (involved versus uninvolved) comparisons.

Results: There was a main effect of group (p = .039) for peak knee flexion angle (PKFA). Participants after partial medial meniscectomy walked with clinically meaningfully smaller PKFAs in both the involved and uninvolved limbs compared to the no medial meniscus involvement group (group mean difference [95%CI]; involved: -4.9°[-8.7°, -1.0°], p = .015; uninvolved: -3.9°[-7.6°, -0.3°], p = .035) and medial meniscus repair group (involved: -5.2°[-9.9°, -0.6°], p = .029; uninvolved: -4.7°[-9.0°, -0.3°], p = .038). The partial medial meniscectomy group walked with higher involved versus uninvolved limb medial tibiofemoral contact forces (0.45 body weights, 95% CI: -0.01, 0.91 BW, p = 0.053) and truncated sagittal plane knee excursions, which were not present in the other two groups.

Significance: Aberrant gait biomechanics may concentrate high forces in the antero-medial tibiofemoral cartilage among patients two years after ACLR plus partial medial meniscectomy, perhaps explaining the higher osteoarthritis rates and offering an opportunity for targeted interventions.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.gaitpost.2019.08.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790293PMC
October 2019

Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts.

Orthop J Sports Med 2019 Aug 1;7(8):2325967119861311. Epub 2019 Aug 1.

Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA.

Background: Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential.

Purpose: (1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo).

Study Design: Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3.

Methods: A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes.

Results: No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores ( < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS-Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON ( = .011).

Conclusion: Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR.

Registration: NCT01773317 (ClinicalTrials.gov identifier).
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http://dx.doi.org/10.1177/2325967119861311DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676263PMC
August 2019

Gait Mechanics in Women of the ACL-SPORTS Randomized Control Trial: Interlimb Symmetry Improves Over Time Regardless of Treatment Group.

J Orthop Res 2019 08 20;37(8):1743-1753. Epub 2019 May 20.

Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware.

Women after anterior cruciate ligament (ACL) injury and ACL reconstruction (ACLR) are more likely than men to exhibit asymmetric movement patterns, which are associated with post-traumatic osteoarthritis. We developed the ACL specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of strength, agility, plyometric, and secondary prevention (SAPP) training with and without perturbation training (SAPP + PERT) on gait mechanics in women after ACLR. We hypothesized that movement symmetry would improve over time across both groups but more so among the SAPP + PERT group. Thirty-nine female athletes 3-9 months after primary ACLR were randomized to SAPP or SAPP + PERT training. Biomechanical testing during overground walking occurred before (Pre-training) and after (Post-training) training and one and 2 years post-operatively. Hip and knee kinematic and kinetic variables were compared using repeated measures analysis of variance with Bonferroni corrections for post hoc comparisons (α = 0.05). There was a time by limb interaction effect (p = 0.028) for peak knee flexion angle (PKFA), the primary outcome which powered the study, characterized by smaller PKFA in the involved compared to uninvolved limbs across treatment groups at Pre-training, Post-training, and 1 year, but not 2 years. Similar findings occurred across sagittal plane knee excursions and kinetics and hip extension excursion at midstance. There were no meaningful interactions involving group. Neither SAPP nor SAPP + PERT training improved walking mechanics, which persisted 1 but not 2 years after ACLR. Statement of clinical significance: Asymmetrical movement patterns persisted long after participants achieved symmetrical strength and functional performance, suggesting more time is needed to recover fully after ACLR. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1743-1753, 2019.
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http://dx.doi.org/10.1002/jor.24314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824924PMC
August 2019

Psychological Readiness to Return to Sport Is Associated With Knee Kinematic Asymmetry During Gait Following Anterior Cruciate Ligament Reconstruction.

J Orthop Sports Phys Ther 2018 12 27;48(12):968-973. Epub 2018 Jul 27.

Background: Gait asymmetry is frequently observed following anterior cruciate ligament reconstruction (ACLR). Psychological readiness to return to sport is associated with functional and activity-related outcomes after ACLR. However, the association between gait asymmetry and psychological readiness to return to sport is unknown.

Objectives: To determine the relationship between kinematic and kinetic measures of knee symmetry during gait and psychological readiness to return to sport following ACLR.

Methods: In this controlled laboratory, cross-sectional study, 79 athletes (39 women) underwent gait analysis following impairment resolution after ACLR (ie, full range of motion, minimal or no effusion, quadriceps strength index of 80% or greater). Interlimb differences during gait were calculated for sagittal plane knee angles at initial contact, peak knee flexion, and peak knee extension, as well as for peak knee flexion moment and peak knee adduction moment. Athletes completed the Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI) to assess psychological readiness to return to sport. Pearson correlations were used to examine the association between ACL-RSI score and each gait symmetry variable.

Results: Significant negative correlations were observed between the ACL-RSI and 2 kinematic variables: knee flexion angle at initial contact (r = -0.281, P = .012) and peak knee flexion (r = -0.248, P = .027). In general, lower scores on the ACL-RSI were associated with greater interlimb asymmetry.

Conclusion: There was a weak association between psychological readiness to return to sport and knee kinematic asymmetry during gait. J Orthop Sports Phys Ther 2018;48(12):968-973. Epub 27 Jul 2018. doi:10.2519/jospt.2018.8084.
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http://dx.doi.org/10.2519/jospt.2018.8084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501559PMC
December 2018

TWO YEAR ACL REINJURY RATE OF 2.5%: OUTCOMES REPORT OF THE MEN IN A SECONDARY ACL INJURY PREVENTION PROGRAM (ACL-SPORTS).

Int J Sports Phys Ther 2018 Jun;13(3):422-431

Department of Physical Therapy, University of Delaware, Newark, USA.

Background: The Anterior Cruciate Ligament-Specialized Post-Operative Return to Sports (ACL-SPORTS) randomized control trial (RCT) examined an evidence-based secondary ACL injury prevention training program, involving progressive strengthening, agility training, and plyometrics. The RCT examined the benefit of the training program with and without a neuromuscular training technique called perturbation training.

Hypothesis/purpose: The purpose of this study was to report the return to sport and second ACL injury incidence outcomes of the men in the ACL-SPORTS trial.

Study Design: Secondary analysis of a RCT.

Methods: Forty cutting and pivoting sport male athletes participated in the ACL-SPORTS trial, return to sport testing, and in follow-up sessions at one and two years after ACL reconstruction. Variables of interest at one and two years were return to sport, return to preinjury level of sport, and second ACL injuries. Mean time to passing return to sport criteria, the number of athletes returning to sport and preinjury level of sport and the incidence proportion of second ACL injuries were calculated.

Results: Athletes passed return to sport criteria 232 ± 99 days after ACLR. One year after ACL reconstruction 95% had returned to sport, 78% at their preinjury level. Two years after ACL reconstruction all athletes had returned to sport, 95% at their preinjury level and only one athlete had a second ACL injury.

Conclusions: The results of this study indicate that men in the ACL-SPORTS trial had much higher return to sport rates and much lower second ACL injury rates than those reported in the literature.

Level Of Evidence: 1b.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6044585PMC
June 2018

Gait Mechanics After ACL Reconstruction Differ According to Medial Meniscal Treatment.

J Bone Joint Surg Am 2018 Jul;100(14):1209-1216

University of Delaware, Newark, Delaware.

Background: Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both. Although osteoarthritis development is multifactorial, altered walking mechanics may influence osteoarthritis progression. The purpose of this study was to compare gait mechanics after ACLR among participants who had undergone no medial meniscal surgery, partial medial meniscectomy, or medial meniscal repair.

Methods: This was a secondary analysis of data collected prospectively as part of a clinical trial. Sixty-one athletes (mean age of 21.4 ± 8.2 years) who had undergone primary ACLR participated in the study when they achieved impairment resolution (5.3 ± 1.7 months postoperatively), including minimal to no effusion, full knee range of motion, and ≥80% quadriceps-strength symmetry. Participants were classified by concomitant medial meniscal treatment: no involvement or nonsurgical management of a small, stable tear; partial meniscectomy; or meniscal repair. Participants underwent comprehensive walking analyses. Joint contact forces were estimated using a previously validated, electromyography-driven musculoskeletal model. Variables were analyzed using a mixed-model analysis of variance with group and limb comparisons (α = 0.05); group comparisons of interlimb differences in measurements (surgical minus contralateral limb) were performed to determine significant interactions.

Results: The participants in the partial meniscectomy group walked with a higher peak knee adduction moment (pKAM) in the surgical versus the contralateral limb as compared with those in the meniscal repair group and those with no medial meniscal surgery (group difference for partial versus repair: 0.10 N-m/kg-m, p = 0.020; and for partial versus none: 0.06 N-m/kg-m, p = 0.037). Participants in the repair group walked with a smaller percentage of medial to total tibiofemoral loading in the surgical limb compared with both of the other groups (group difference for repair versus partial: -12%, p = 0.001; and for repair versus none: -7%, p = 0.011). The participants in the repair group loaded the medial compartment of the surgical versus the contralateral limb 0.5 times body weight less than did the participants in the partial meniscectomy group.

Conclusions: Participants in the partial meniscectomy group walked with higher pKAM and shifted loading toward the medial compartment of the surgical limb, while participants in the repair group did the opposite, walking with lower pKAM and unloading the surgical limb relative to the contralateral limb. These findings may partially explain the conflicting evidence regarding pKAM after ACLR and the elevated risk for osteoarthritis (whether from overloading or underloading) after ACLR with concomitant medial meniscectomy or repair.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.01014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6636792PMC
July 2018

Functional and Patient-Reported Outcomes Improve Over the Course of Rehabilitation: A Secondary Analysis of the ACL-SPORTS Trial.

Sports Health 2018 Sep/Oct;10(5):441-452. Epub 2018 Jun 20.

Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware.

Background: The Anterior Cruciate Ligament-Specialized Post-Operative Return to Sports (ACL-SPORTS) randomized controlled trial was designed to address deficits in functional and patient-reported outcomes. The trial examined the effects of a secondary ACL prevention program that included progressive strengthening, agility training, plyometrics (SAP), and other components of current primary prevention protocols, with perturbation training (SAP + PERT group) and without PERT (SAP group). A secondary purpose of this study was to examine whether study outcomes differed between men and women.

Hypotheses: (1) Athletes in both the SAP and SAP + PERT groups will have improved knee function and patient-reported outcome measures from pre- to posttraining, (2) the SAP + PERT group would have higher outcome scores than the SAP group, and (3) outcomes will differ by sex.

Study Design: Randomized controlled trial (NCT01773317).

Level Of Evidence: Level 2.

Methods: A total of 79 athletes (39 women) were randomized into the SAP and SAP + PERT groups. All athletes had undergone primary ACL reconstruction and achieved 80% quadriceps strength limb symmetry (QI), full range of motion, had minimal effusion, and had no pain. Additionally, all had begun running again. Prior to and after the training program, athletes' QI, hopping, and patient-reported outcomes were assessed. Repeated-measures analyses of variance were used to determine whether there were differences between groups. Subsequently, the SAP and SAP + PERT groups were collapsed to analyze differences between sexes.

Results: There were significant increases for all variables, with the exception of QI. There were no differences between the SAP and SAP + PERT groups. Both men and women made significant improvements in all knee function and patient-reported outcome measures except QI. Men made significant improvements in QI, whereas women did not.

Conclusion: The common elements of the training program that all athletes received (10 sessions of progressive strengthening, agility training, plyometrics, and secondary prevention) may be a beneficial addition to the return-to-sport phase of ACL reconstruction rehabilitation. The results suggest that women may require further quadriceps strengthening to maintain and improve QI, an important focus given the relationship between QI and risk for reinjury.

Clinical Relevance: During the return-to-sport phase of ACL reconstruction rehabilitation, clinicians tend to shift their focus away from strengthening toward more advanced sports-related tasks. These results indicate that women in particular need continued focus on quadriceps strengthening.
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http://dx.doi.org/10.1177/1941738118779023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6116107PMC
September 2018

Gait mechanics and tibiofemoral loading in men of the ACL-SPORTS randomized control trial.

J Orthop Res 2018 09 24;36(9):2364-2372. Epub 2018 Apr 24.

Biomechanics and Movement Science, University of Delaware, Newark, Delaware.

The risk for post-traumatic osteoarthritis is elevated after anterior cruciate ligament reconstruction (ACLR), and may be especially high among individuals with aberrant walking mechanics, such as medial tibiofemoral joint underloading 6 months postoperatively. Rehabilitation training programs have been proposed as one strategy to address aberrant gait mechanics. We developed the anterior cruciate ligament specialized post-operative return-to-sports (ACL-SPORTS) randomized control trial to test the effect of 10 post-operative training sessions consisting of strength, agility, plyometric, and secondary prevention exercises (SAPP) or SAPP plus perturbation (SAPP + PERT) training on gait mechanics after ACLR. A total of 40 male athletes (age 23 ± 7 years) after primary ACLR were randomized to SAPP or SAPP + PERT training and tested at three distinct, post-operative time points: 1) after impairment resolution (Pre-training); 2) following 10 training sessions (Post-training); and 3) 2 years after ACLR. Knee kinematic and kinetic variables as well as muscle and joint contact forces were calculated via inverse dynamics and a validated electromyography-informed musculoskeletal model. There were no significant improvements from Pre-training to Post-training in either intervention group. Smaller peak knee flexion angles, extension moments, extensor muscle forces, medial compartment contact forces, and tibiofemoral contact forces were present across group and time, however the magnitude of interlimb differences were generally smaller and likely not meaningful 2 years postoperatively. Neither SAPP nor SAPP + PERT training appears effective at altering gait mechanics in men in the short-term; however, meaningful gait asymmetries mostly resolved between post-training and 2 years after ACLR regardless of intervention group. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2364-2372, 2018.
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http://dx.doi.org/10.1002/jor.23895DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157011PMC
September 2018

On-Ice Return-to-Hockey Progression After Anterior Cruciate Ligament Reconstruction.

J Orthop Sports Phys Ther 2017 May 29;47(5):324-333. Epub 2017 Mar 29.

Synopsis The literature pertaining to the rehabilitation of ice hockey players seeking to return to sport after anterior cruciate ligament reconstruction (ACLR) is currently limited. The purpose of this clinical commentary was to present a criterion-based progression for return to ice hockey for athletes after ACLR. First, we review pertinent literature and provide previously published guidelines on general rehabilitation after ACLR. Then, we present a 4-phase, on-ice skating progression with objective criteria to initiate each phase. During the early on-ice phase, the athlete is reintroduced to specific demands, including graded exposure to forward, backward, and crossover skating. In the intermediate on-ice phase, the emphasis shifts to developing power and introducing anticipated changes of direction within a controlled environment. During the late on-ice phase, the focus progresses to developing anaerobic endurance and introducing unanticipated changes of direction, but still without other players or contact. Finally, once objective return-to-sport criteria are met, noncontact team drills, outnumbered and even-numbered drills, practices, scrimmages, and games are progressively reintroduced during the return-to-sport phase. Recommendations for off-ice strength and conditioning exercises complement the on-ice progression. Additionally, we apply the return-to-hockey progression framework to a case report of a female collegiate defensive ice hockey player who returned to sport successfully after ACLR. This criterion-based return-to-hockey progression may guide rehabilitation specialists managing athletes returning to ice hockey after ACLR. J Orthop Sports Phys Ther 2017;47(5):324-333. Epub 29 Mar 2017. doi:10.2519/jospt.2017.7245.
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http://dx.doi.org/10.2519/jospt.2017.7245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5480966PMC
May 2017

Report of the Clinical and Functional Primary Outcomes in Men of the ACL-SPORTS Trial: Similar Outcomes in Men Receiving Secondary Prevention With and Without Perturbation Training 1 and 2 Years After ACL Reconstruction.

Clin Orthop Relat Res 2017 Oct;475(10):2523-2534

Biomechanics and Movement Science Program, University of Delaware, 540 South College Avenue, Newark, DE, 19711, USA.

Background: Athletes often are cleared to return to activities 6 months after anterior cruciate ligament (ACL) reconstruction; however, knee function measures continue to improve up to 2 years after surgery. Interventions beyond standard care may facilitate successful return to preinjury activities and improve functional outcomes. Perturbation training has been used in nonoperative ACL injury and preoperative ACL reconstruction rehabilitation, but has not been examined in postoperative ACL reconstruction rehabilitation, specifically return to sport rehabilitation.

Questions/purposes: The purpose of this study was to determine whether there were differences at 1 and 2 years after ACL reconstruction between the male SAP (strengthening, agility, and secondary prevention) and SAP+PERT (SAP protocol with the addition of perturbation training) groups with respect to (1) quadriceps strength and single-legged hop limb symmetry; (2) patient-reported knee outcome scores; (3) the proportion who achieve self-reported normal knee function; and (4) the time from surgery to passing return to sport criteria.

Methods: Forty men who had completed ACL reconstruction rehabilitation and met enrollment criteria (3-9 months after ACL reconstruction, > 80% quadriceps strength limb symmetry, no pain, full ROM, minimal effusion) were randomized into the SAP or SAP+PERT groups of the Anterior Cruciate Ligament-Specialised Post-Operative Return to Sports trial (ACL-SPORTS), a single-blind randomized clinical study of secondary prevention and return to sport. Quadriceps strength, single-legged hopping, the International Knee Documentation Committee (IKDC) 2000 subjective knee form, Knee Injury and Osteoarthritis Outcome Score (KOOS)-sports and recreation, and KOOS-quality-of-life subscales were collected 1 and 2 years after surgery by investigators blind to group. Athletes were categorized as having normal or abnormal knee function at each time point based on IKDC score, and the time until athletes passed strict return-to-sport criteria was also recorded. T-tests, chi square tests, and analyses of variance were used to identify differences between the treatment groups over time.

Results: There were no differences between groups for quadriceps symmetry (1 year: SAP = 101% ± 14%, SAP+PERT = 101% ± 14%; 2 years: SAP = 103% ± 11%, SAP+PERT = 98% ± 14%; mean differences between groups at 1 year: 0.4 [-9.0 to 9.8], 2 years = 4.5 [-4.3 to 13.1]; mean difference between 1 and 2 years: SAP = -1.0 [-8.6 to 6.6], SAP+PERT = 3.0 [-4.3 to 10.3], p = 0.45) or single-legged hop test limb symmetry. There were no clinically meaningful differences for any patient-reported outcome measures. There was no difference in the proportion of athletes in each group who achieved normal knee function at 1 year (SAP 14 of 19, SAP+PERT 18 of 20, odds ratio 0.31 [0.5-19.0]; p = 0.18); however, the SAP+PERT group had fewer athletes with normal knee function at 2 years (SAP 17 of 17, SAP+PERT 14 of 19, p = 0.03). There were no differences between groups in the time to pass return to sport criteria (SAP = 325 ± 199 days, SAP+PERT = 233 ± 77 days; mean difference 92 [-9 to 192], p = 0.09).

Conclusions: This randomized trial found few differences between an ACL rehabilitation program consisting of strengthening, agility, and secondary prevention and one consisting of those elements as well as perturbation training. In the absence of clinically meaningful differences between groups in knee function and self-reported outcomes measures, the results indicate that perturbation training may not contribute additional benefit to the strengthening, agility, and secondary prevention base of the ACL-SPORTS training program.

Level Of Evidence: Level II, therapeutic study.
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http://dx.doi.org/10.1007/s11999-017-5280-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5599384PMC
October 2017

Gait mechanics and second ACL rupture: Implications for delaying return-to-sport.

J Orthop Res 2017 09 18;35(9):1894-1901. Epub 2016 Nov 18.

Biomechanics and Movement Science, University of Delaware, Newark, Delaware.

Second anterior cruciate ligament rupture is a common and devastating injury among young women who return to sport after ACL reconstruction, but it is inadequately understood. The purpose of this study was to compare gait biomechanics and return-to-sport time frames in a matched cohort of young female athletes who, after primary ACLR, returned to sport without re-injury or sustained a second ACL injury. Approximately 6 months after primary reconstruction, 14 young women (age 16 ± 2 years) involved in jumping, cutting, and pivoting sports underwent motion analysis testing after physical therapy and impairment resolution. Following objective return-to-sport clearance, seven athletes sustained a second ACL rupture within 20 months of surgery (13.4 ± 4.9 months). We matched them by age, sex, and sport-level to seven athletes who returned to sports without re-injury. Data were analyzed using a previously validated, EMG-informed, patient-specific musculoskeletal model. Compared to athletes without re-injury, athletes who sustained a second ACL injury received surgery sooner (p = 0.023), had post-operative impairments resolved earlier (p = 0.022), reached criterion-based return-to-sport benchmarks earlier (p = 0.024), had higher body mass index (p = 0.039), and walked with lower peak knee flexor muscle forces bilaterally (p = 0.021). Athletes who sustained a second injury also tended to walk with larger (p = 0.089) and more symmetrical peak knee flexion angles and less co-contraction, all indicative of a more normal gait pattern. Statement of Clinical Significance: Delayed return-to-sport clearance even in the absence of gait or clinical impairments following primary ACL reconstruction may be necessary to mitigate second ACL injury risk in young women. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1894-1901, 2017.
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http://dx.doi.org/10.1002/jor.23476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423861PMC
September 2017
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