Abstract
Purpose
National registry data have established Knee injury and Osteoarthritis Outcome Score (KOOS) functional recovery target values for adults after anterior cruciate ligament (ACL) reconstruction. However, the specificity of these target values for young athletes after ACL reconstruction is unclear. The purpose of this analysis was to (1) derive age- and activity-relevant KOOS functional recovery target values from uninjured young athlete data and (2) determine clinical measures at the time of RTS clearance associated with meeting the newly-derived functional recovery target values in young athletes following ACLR.
Methods
Two hundred and twenty-two young athletes (56 uninjured controls, 17.2 ± 2.4 years, 73% female; 166 after ACL reconstruction, 16.9 ± 2.2 years, 68% female) were included in this cross-sectional analysis from a larger cohort study. Uninjured control participants completed the KOOS, and functional recovery target values were defined as the lower bound of the 95% confidence interval for KOOS subscales. ACL reconstruction participants completed testing within 4 weeks of return-to-sport clearance, including the KOOS, single-leg hop tests, and isometric quadriceps strength. In ACL reconstruction participants, logistic regression was used to determine predictors of meeting all KOOS functional recovery target values (primary outcome) among demographic/injury, hop, and strength data (α ≤ 0.05).
Results
KOOS functional recovery target values for each subscale from uninjured athlete data were: Pain ≥ 94, Symptoms ≥ 92, Activities of Daily Living ≥ 97, Sport ≥ 92, and Quality-of-Life ≥ 92. At the time of return-to-sport clearance, ACL reconstruction participants met the KOOS functional recovery targets in the following proportions: Pain, 63%; Symptoms, 42%; Activities of Daily Living, 80%; Sport, 45%; Quality-of-Life, 24%; overall functional recovery (met all subscale targets), 17%. In ACL reconstruction participants, significant predictors of overall functional recovery (primary outcome) were: younger age, hamstring graft, pediatric ACL reconstruction, quadriceps strength limb-symmetry index > 90%, single-hop limb-symmetry index > 90%, and crossover-hop limb-symmetry index > 90%.
Conclusions
KOOS functional recovery target values derived from uninjured young athletes were higher than those previously reported. Small proportions of young athletes following recent RTS clearance after ACLR met these newly-derived functional recovery target values, and factors associated with meeting functional recovery target values included younger age, hamstring autograft and pediatric ACLR, and having > 90% LSI for quadriceps strength and single-leg hop tests.
Level of evidence
I.
Similar content being viewed by others
References
Abernethy P, Wilson G, Logan P (1995) Strength and power assessment. Issues, controversies and challenges. Sports Med 19:401–417
Barenius B, Forssblad M, Engstrom B, Eriksson K (2013) Functional recovery after anterior cruciate ligament reconstruction, a study of health-related quality of life based on the Swedish National Knee Ligament Register. Knee Surg Sports Traumatol Arthrosc 21:914–927
Beynnon BD, Johnson RJ, Abate JA, Fleming BC, Nichols CE (2005) Treatment of anterior cruciate ligament injuries, part I. Am J Sports Med 33:1579–1602
Dingenen B, Gokeler A (2017) Optimization of the return-to-sport paradigm after anterior cruciate ligament reconstruction: a critical step back to move forward. Sports Med 47:1487–1500
Frobell RB, Svensson E, Göthrick M, Roos EM (2008) Self-reported activity level and knee function in amateur football players: The influence of age, gender, history of knee injury and level of competition. Knee Surg Sports Traumatol Arthrosc 16:713–719
Gokeler A, Welling W, Zaffagnini S, Seil R, Padua D (2017) Development of a test battery to enhance safe return to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 25:192–199
Hambly K, Griva K (2010) IKDC or KOOS: which one captures symptoms and disabilities most important to patients who have undergone initial anterior cruciate ligament reconstruction? Am J Sports Med 38:1395–1404
Ithurburn MP, Altenburger AR, Thomas S, Hewett TE, Paterno MV, Schmitt LC (2018) Young athletes after ACL reconstruction with quadriceps strength asymmetry at the time of return-to-sport demonstrate decreased knee function 1 year later. Knee Surg Sports Traumatol Arthrosc 26:426–433
Ithurburn MP, Longfellow MA, Thomas S, Paterno MV, Schmitt LC (2019) Knee function, strength, and resumption of preinjury sports participation in young athletes following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 49:145–153
Ithurburn MP, Paljieg A, Thomas S, Hewett TE, Paterno MV, Schmitt LC (2019) Strength and function across maturational levels in young athletes at the time of return to sport after ACL reconstruction. Sports Health 11:324–331
Ithurburn MP, Paterno MV, Ford KR, Hewett TE, Schmitt LC (2015) Young athletes with quadriceps femoris strength asymmetry at return to sport after anterior cruciate ligament reconstruction demonstrate asymmetric single-leg drop-landing mechanics. Am J Sports Med 43:2727–2737
Ithurburn MP, Paterno MV, Thomas S, Pennell ML, Evans KD, Magnussen RA et al (2019) Clinical measures associated with knee function over two years in young athletes after ACL reconstruction. Knee 26:355–363
Kvist J (2004) Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med 34:269–280
Logerstedt DS, Scalzitti D, Risberg MA, Engebretsen L, Webster KE, Feller J et al (2017) Knee stability and movement coordination impairments: knee ligament sprain revision 2017. J Orthop Sports Phys Ther 47:A1–A47
Losciale JM, Zdeb RM, Ledbetter L, Reiman MP, Sell TC (2019) The association between passing return-to-sport criteria and second anterior cruciate ligament injury risk: a systematic review with meta-analysis. J Orthop Sports Phys Ther 49:43–54
Lynch AD, Logerstedt DS, Grindem H, Eitzen I, Hicks GE, Axe MJ et al (2015) Consensus criteria for defining “successful outcome” after ACL injury and reconstruction: a Delaware-Oslo ACL cohort investigation. Br J Sports Med 49:335–342
Marot V, Murgier J, Carrozzo A, Reina N, Monaco E, Chiron P et al (2019) Determination of normal KOOS and WOMAC values in a healthy population. Knee Surg Sports Traumatol Arthrosc 27:541–548
Paradowski PT, Bergman S, Sunden-Lundius A, Lohmander LS, Roos EM (2006) Knee complaints vary with age and gender in the adult population. Population-based reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS). BMC Musculoskelet Disord 7:38
Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR (1996) A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 49:1373–1379
Prodromos CC, Han Y, Rogowski J, Joyce B, Shi K (2007) A meta-analysis of the incidence of anterior cruciate ligament tears as a function of gender, sport, and a knee injury-reduction regimen. Arthroscopy 23:1320-1325 e1326
Reid A, Birmingham TB, Stratford PW, Alcock GK, Giffin JR (2007) Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Phys Ther 87:337–349
Roos E, Roos H, Lohmander L, Ekdahl C, Beynnon B (1998) Knee Injury and Osteoarthritis Outcome Score (KOOS)–development of a self-administered outcome measure. J Orthop Sports Phys Ther 28:88–96
Roos EM, Lohmander LS (2003) The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes 1:64
Ross MD, Irrgang JJ, Denegar CR, McCloy CM, Unangst ET (2002) The relationship between participation restrictions and selected clinical measures following anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 10:10–19
Salavati M, Akhbari B, Mohammadi F, Mazaheri M, Khorrami M (2011) Knee injury and Osteoarthritis Outcome Score (KOOS); reliability and validity in competitive athletes after anterior cruciate ligament reconstruction. Osteoarthritis Cartilage 19:406–410
Schmitt LC, Paterno MV, Ford KR, Myer GD, Hewett TE (2015) Strength asymmetry and landing mechanics at return to sport after anterior cruciate ligament reconstruction. Med Sci Sports Exerc 47:1426–1434
Schmitt LC, Paterno MV, Hewett TE (2012) The impact of quadriceps femoris strength asymmetry on functional performance at return to sport following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther 42:750–759
Stark T, Walker B, Phillips JK, Fejer R, Beck R (2011) Hand-held dynamometry correlation with the gold standard isokinetic dynamometry: a systematic review. PM R 3:472–479
Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49
Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, Schmitt LC (2017) Young athletes cleared for sports participation after anterior cruciate ligament reconstruction: how many actually meet recommended return-to-sport criterion cutoffs? J Orthop Sports Phys Ther 47:825–833
van Melick N, van Cingel RE, Brooijmans F, Neeter C, van Tienen T, Hullegie W et al (2016) Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med 50:1506–1515
Wasserstein D, Huston LJ, Nwosu S, Group M, Kaeding CC, Parker RD et al (2015) KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study. Osteoarthritis Cartilage 23:1674–1684
Webster KE, Hewett TE (2019) What is the evidence for and validity of return-to-sport testing after anterior cruciate ligament reconstruction surgery? A systematic review and meta-analysis. Sports Med 49:917–929
Welling W, Benjaminse A, Seil R, Lemmink K, Zaffagnini S, Gokeler A (2018) Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc 26:3636–3644
Xergia SA, McClelland JA, Kvist J, Vasiliadis HS, Georgoulis AD (2011) The influence of graft choice on isokinetic muscle strength 4–24 months after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 19:768–780
Acknowledgements
We would like to thank the staff of the Division of Sports Medicine and the Sports and Orthopaedic Team in the Division of Occupational Therapy and Physical Therapy for their contribution to this work.
Funding
This study was funded by support from the National Institutes of Health grant F32-AR055844 and the National Football League Charities Medical Research Grants 2007, 2008, 2009, and 2011. The funding agencies had no role in the study design, collection, analysis, nor interpretation of the data presented. Additionally, the funding agencies had no involvement in the writing of the manuscript, nor the decision to submit the manuscript for publication.
Author information
Authors and Affiliations
Contributions
The conception and design of the study, or acquisition of data, or analysis and interpretation of data: MPI, BB, ST, MVP, LCS. Drafting the article or revising it critically for important intellectual content: MPI, BB, ST, MVP, LCS. Final approval of the version to be submitted: MPI, BB, ST, MVP, LCS. All authors take responsibility for the integrity of the work as a whole.
Corresponding author
Ethics declarations
Conflict of interest
We have no competing interests or conflicts of interest to declare for this study.
Ethical approval of research on humans
The Institutional Review Board at Cincinnati Children’s Hospital Medical Center (Cincinnati, Ohio, USA) approved the protocol for this study (Project 2008-0514).
Informed consent
All participants provided written informed consent or parental permission/assent (when younger than 18 years old) prior to participating in the study.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Ithurburn, M.P., Barenius, B., Thomas, S. et al. Few young athletes meet newly derived age- and activity-relevant functional recovery targets after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 30, 3268–3276 (2022). https://doi.org/10.1007/s00167-021-06769-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00167-021-06769-4