Potential Copers Research Articles

Age, activity level and meniscus injury, but not tear location, tibial slope or anterolateral ligament injury predict coping with anterior cruciate ligament injury

IntroductionEarly recognition of potential predictors on the success of conservative treatment of anterior cruciate ligament (ACL) is important, as appropriate treatment can be applied to each individual patient. The goal of this study is to assess the patient demographic and radiological parameters that predict coping with ACL injuries. MethodsAll patients presenting with a complete ACL injury between 2014 and 2018 at our clinic were included. The role of patient demographics (age, gender, activity level, meniscus injury and time from injury to clinic), and ACL tear location, bone bruises, tibial slope, and anterolateral ligament (ALL) injury were assessed on the success of conservative treatment using univariate and multivariate analyses. ResultsSixty-five patients (32%) were copers and 141 (68%) were non-copers. Univariate analysis showed that copers were significantly older (40 vs. 27 years, P < 0.001), had lower preinjury activity level (Tegner 5.7 vs. 6.5, P < 0.001) and less often lateral meniscus tears (16% vs. 5%, P = 0.019) but not medial meniscus tears (17% vs. 14%, P = 0.609) than non-copers. Multivariate analysis revealed that increasing age (P < 0.001), Tegner level ≤ 6 (P = 0.003) and no meniscus injury (P = 0.045) were independent predictors of coping with ACL deficiency. ConclusionsOlder age, participation in lower activity sports levels and absence of meniscus injury were predictive of coping with ACL deficiency, whereas there was no such role for tear location, tibial slope, lateral bone bruise presence, ALL injury or gender. These findings might help to identify potential copers and guide surgeons early in the optimal treatment for patients with ACL injury.

Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study

Background: Some athletes demonstrate excellent dynamic stability after anterior cruciate ligament (ACL) rupture and return to sport without ACL reconstruction (ACLR) (copers). Others demonstrate persistent instability despite rehabilitation (noncopers) and require surgical stabilization. Testing to determine coper classification can identify potential copers early after rupture. It is unclear how coper classification changes after a brief intervention and how early classification relates to long-term outcomes. Purpose: (1) To evaluate the consistency of early coper classification (potential coper vs noncoper) before and after progressive neuromuscular and strength training (NMST) among athletes early after acute ACL rupture and (2) to evaluate the association of early coper classification with 2-year success after ACL rupture. Study Design: Cohort study; Level of evidence, 2. Methods: This was a prospective analysis from the Delaware-Oslo ACL Cohort Study, composed of athletes consecutively enrolled early after ACL rupture. Participants (n = 271) were tested and classified as potential copers or noncopers according to established criteria before and after a 10-session NMST program. Success 2 years after ACLR or nonoperative rehabilitation was defined as meeting or exceeding sex- and age-matched norms for knee function, no ACL graft rupture, and ≤1 episode of giving way within the previous year. The McNemar test evaluated changes in coper classification pre- to posttraining. Logistic regression adjusted for baseline characteristics was used to evaluate the association of early coper classification and surgical status with 2-year success. Results: Of 300 athletes enrolled, 271 (90%) completed the posttraining data collection, and 219 (73%) returned for the 2-year follow-up. The coper classifications were different between time points: nearly half of those classified initially as noncopers became potential copers (P < .001). At the 2-year follow-up, 66% of the ACLR group and 74% of the nonoperative group were successful. Athletes who were potential copers posttraining and chose ACLR or nonoperative rehabilitation had 2.7 (95% CI, 1.3-5.6) and 2.9 (95% CI, 1.2-7.2) times the odds of success, respectively, as compared with noncopers who chose ACLR. Conclusion: Coper classification improved after NMST; more athletes became potential copers. Athletes who were potential copers after NMST were more likely to succeed 2 years later regardless of whether they had surgery, strongly supporting the addition of NMST before ACLR. Persistent noncopers fared poorly, indicating that more intensive rehabilitation may be needed.

Early osteoarthritis following conservatively treated anterior cruciate ligament injuries

Background: One of the most disturbing long term sequelae of an anterior cruciate ligament (ACL) injury is the development of early onset osteoarthritis (OA) in younger people. Controversy exists regarding whether surgical or non-surgical approaches to treatment are associated with the development of OA. An earlier study by the authors has shown that no statistically significant difference exists in OA between patients treated surgically or conservatively at 12 years post injury. However when the surgical groups were sub-grouped into patellar-tendon (PT) and semitendinosus/gracilis (STG) grafting groups, significantly less OA was found in the STG group. It is possible that sub-grouping conservatively treated ACL patients may provide similar insights regarding the development of OA. Purpose: This study aimed to compare the incidence of tibiofemoral and patellofemoral OA in 3 sub-groups of conservatively treated ACL patients namely, an unstable (non-copers), an equivocally stable (potential copers or adaptors) and a stable (copers) sub-group, at 12 years post injury. Methods: 52 conservatively managed ACL injured patients, were recruited from a cohort of 297 ACL injured patients previously referred to one physiotherapy clinic. These comprised 32 males and 20 females, mean aged 40 years. Patients were included in the study if they had a ruptured ACL on MRI, arthroscopy or clinical examination by an orthopaedic surgeon and had no reconstructive surgery. 34 patients with meniscal injuries were included. Assessment included subjective, instrumented (KT 1000) and clinical stability testing. According to their levels of stability the patients were sub-grouped into stable, equivocally stable and unstable sub-groups. Bilateral knee radiographs were taken and graded by an independent radiologist blind to the aims of the study. Tibiofemoral and patellofemoral OA was graded as absent, mild, moderate or severe based on the Kellgren model. An ANOVA was conducted to compare the incidence and severity of OA between the 3 sub-groups. Results: 15 patients had unstable ACL-deficient knees, 23 had equivocally stable knees and 14 had stable ACL-deficient knees. Overall 63% of patients developed tibiofemoral and 44% developed patellofemoral OA. 80% of the unstable group, 63% of the equivocal group and 50% of the stable group developed tibiofemoral OA. ANOVA studies revealed that there was a statistically significant difference in the incidence of tibiofemoral OA between the stable and unstable group (p = 0.017). No differences were found for the development of patellofemoral OA. Conclusion(s): Very few long-term follow-up studies of conservatively managed ACL cohorts exist. This study has shown that among ACL-injured patients at 12 years post injury, there exists a group that remains stable and is able to return to the same sporting level as prior to injury. This stable group developed significantly less tibiofemoral OA in the long term compared to less stable groups. Implications: This study has highlighted the importance of detailed assessment of ACL injured patients into stability groups prior to making decisions re surgery. It is possible that the more stable knee treated conservatively may develop less OA than if treated surgically.

Contributing factors in children who present with calcaneal apophysitis

Background: Rupture of the Anterior Cruciate Ligament (ACL) results in increased tibiofemoral laxity and usually disturbs neuromuscular function, thereby ultimately resulting in knee instability and dysfunction. However, ACL rupture does not automatically result in functional impairment and instability, as confirmed by the ACL deficient (ACLD) coper, who can resume pre-morbid activity levels. Few studies have shown that ACL reconstruction (ACLR) actually restores dynamic knee stability or enables full return to pre-injury activity level in most individuals. The purpose of this meta-analysis was to review the dilemma regarding which ACL injured individuals need to undergo ACLR. Methods: Electronic searches of Medline, EMBase, CINAHL and the Musculoskeletal Injuries Group’s specialized register were performed up to June 2009 using medical subject headings and free-text words. Subject-specific search was based on the terms “ACL rehabilitation”, “copers” “noncopers”. Results: Three prospective, longitudinal trials have been undertaken following an ACL screening examination. Copers (nonoperated) and noncopers (operated) have been followed over a few years post-injury. The results show that a similar percentage of subjects in both groups return to sporting activity. Regarding the differences between copers and noncopers, there exists investigative evidence that noncopers have deficits in quadriceps strength, vastus lateralis atrophy, quadriceps activation deficits, altered knee movement patterns, reduced knee flexion moment, higher quadriceps/hamstring co-contraction and a tendency to hold the tibia in a more posterior position. Conclusion: No single measurement tool is sufficient in determining the functional status of the ACLD individual. Passive instability tests are a poor predictor of future rehabilitation outcome. A collaboration of tests to determine the functional status of the ACL deficient individual is recommended, specifically incorporating the KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index. The ACL screening examination shows preliminary evidence for detecting potential copers, however a gold-standard method of detecting who will be successful is still lacking. ACL injured subjects should be informed of the possibility of good knee function following a non-operative rehabilitation program.

How can practitioners decide when to reconstruct a torn anterior cruciate ligament?

Anterior cruciate ligament (ACL) injuries are a common problem with 80,000 ACL injuries in the athletic population and 200,000 in the general population annually in the USA [1,2]. With growth in youth sports and activities, ACL injuries are a problem in the active adolescent population [3]. ACL reconstruction techniques designed to restore knee stability and protect the menisci and cartilage from damage are popular, but the decision of in whom to perform a reconstruction is not as clear as simply identifying a torn ACL on MRI. Some patients can develop functional stability with conservative treatment, while others require operative reconstruction to provide stability. Age, activity level, patient expectations, knee stability, mechanical alignment and cartilage status each play an important role in deciding who will maximally benefit from a surgical intervention versus nonoperative rehabilitation and/or bracing. In addition, one must consider the risk of joint degeneration and osteoarthritis (OA) to the knee with and without a functional ACL. The kinematics and contact mechanics of the knee with and without an ACL or an ACL reconstruction have been studied to provide greater insights into the role of the ACL in joint contact stresses and potentially OA [4]. Patients have a variable ability to function with ACL def iciency based on anatomic differences, activity level and expectations. Noyes et al. proposed a ‘rule of thirds’ in the 1980s [5]. ‘Copers’ are the one third of patients that resume activities and manage well without reconstruction, ‘adapters’ manage by modifying activities and ‘noncopers’ have recurrent instability with activities and require ACL reconstruction to restore functional stability. Very few studies have successfully addressed how to identify the potential copers from the noncopers and thereby focus ACL reconstructive surgery on those patients who will derive maximal benefit. Copers have been shown to have movement patterns consistent with knee stability [6] with significantly less anterior laxity, fewer incidences of instability or episodes Moira M McCarthy*, Suzanne Maher, Asheesh Bedi & Russell F Warren Editorial

Contributing factors in children who present with calcaneal apophysitis

Background: Rupture of the Anterior Cruciate Ligament (ACL) results in increased tibiofemoral laxity and usually disturbs neuromuscular function, thereby ultimately resulting in knee instability and dysfunction. However, ACL rupture does not automatically result in functional impairment and instability, as confirmed by the ACL deficient (ACLD) coper, who can resume pre-morbid activity levels. Few studies have shown that ACL reconstruction (ACLR) actually restores dynamic knee stability or enables full return to pre-injury activity level in most individuals. The purpose of this meta-analysis was to review the dilemma regarding which ACL injured individuals need to undergo ACLR. Methods: Electronic searches of Medline, EMBase, CINAHL and the Musculoskeletal Injuries Group’s specialized register were performed up to June 2009 using medical subject headings and free-text words. Subject-specific search was based on the terms “ACL rehabilitation”, “copers” “noncopers”. Results: Three prospective, longitudinal trials have been undertaken following an ACL screening examination. Copers (nonoperated) and noncopers (operated) have been followed over a few years post-injury. The results show that a similar percentage of subjects in both groups return to sporting activity. Regarding the differences between copers and noncopers, there exists investigative evidence that noncopers have deficits in quadriceps strength, vastus lateralis atrophy, quadriceps activation deficits, altered knee movement patterns, reduced knee flexion moment, higher quadriceps/hamstring co-contraction and a tendency to hold the tibia in a more posterior position. Conclusion: No single measurement tool is sufficient in determining the functional status of the ACLD individual. Passive instability tests are a poor predictor of future rehabilitation outcome. A collaboration of tests to determine the functional status of the ACL deficient individual is recommended, specifically incorporating the KOS-Sport, Global Knee Function Rating, hop tests and Quadriceps Index. The ACL screening examination shows preliminary evidence for detecting potential copers, however a gold-standard method of detecting who will be successful is still lacking. ACL injured subjects should be informed of the possibility of good knee function following a non-operative rehabilitation program.

Differences in Neuromuscular Control and Quadriceps Morphology Between Potential Copers and Noncopers Following Anterior Cruciate Ligament Injury

Prospective cross-sectional study. To compare knee muscle morphology and voluntary neuromuscular control in individuals who sustained an anterior cruciate ligament (ACL) injury and were identified as being capable of avoiding surgery (potential copers) and those who were recommended for surgery (noncopers), within 6 months of injury. Quadriceps atrophy and poor neuromuscular control have been found in noncopers. However, the reasons why some noncopers may be able to avoid surgery remain elusive. Twenty participants (10 ACL-deficient noncopers and 10 ACL-deficient potential copers) were included in this study. Axial spin-echo, T1-weighted magnetic resonance imaging data of the lower extremities were captured. The volume and maximum cross-sectional area (CSA) of each muscle of the quadriceps and hamstrings were calculated following digital reconstruction. In addition, voluntary neuromuscular control was evaluated using an established target-matching task that required participants to produce static isometric loads across the knee joint. Electromyography was acquired from 5 muscles as participants performed the target-matching task. Circular statistics were used to calculate a specificity index to describe how well focused each muscle was activated toward its primary direction of muscle action. The ACL-deficient limb was then compared to the uninvolved limb of the noncopers and potential copers. The vasti (vastus medialis and vastus intermedius) of the involved limb of the noncopers were significantly smaller (P<.031) in comparison to those of their uninvolved limb. The potential copers' vastus lateralis maximum CSA (P = .047), total quadriceps muscle volume (P = .020) and maximum CSA (P = .015), and quadriceps-hamstring ratio volume (P = .021) and maximum CSA (P = .007) demonstrated quadriceps atrophy. However, only the ACL-deficient limb of the older (mean ± SD age, 27.4 ± 11.4 versus 19.9 ± 3.3 years; P = .032) and lower-activity-level (3.3 ± 0.5 versus 3.6 ± 0.5; P = .098) noncoper group demonstrated reduced rectus femoris (P = .057) and lateral hamstring (P = .064) neuromuscular control in comparison to their uninvolved limb. These findings suggest that quadriceps and hamstring muscle function, rather than muscle size, may be an important factor in the varied response early after ACL injury.

Kinesiophobia After Anterior Cruciate Ligament Rupture and Reconstruction: Noncopers Versus Potential Copers

Secondary-analysis, longitudinal cohort study. To compare kinesiophobia levels in noncopers and potential copers at time points spanning pre- and post-anterior cruciate ligament (ACL) reconstruction and to examine the association between changes in kinesiophobia levels and clinical measures. After ACL injury, a screening examination may be used to classify patients as potential copers or noncopers based on dynamic knee stability. Quadriceps strength, single-leg hop performance, and self-reported knee function are worse in noncopers. High kinesiophobia levels after ACL reconstruction are associated with poorer self-reported knee function and lower return-to-sport rates. Kinesiophobia levels have not been examined before ACL reconstruction, across the transition from presurgery to postsurgery, or based on potential coper and noncoper classification. Quadriceps strength indexes, single-leg hop score indexes, self-reported knee function (Knee Outcome Survey activities of daily living subscale, global rating scale), and kinesiophobia (Tampa Scale of Kinesiophobia [TSK-11]) scores were compiled for potential copers (n = 50) and noncopers (n = 61) from 2 clinical trial databases. A repeated-measures analysis of variance was used to compare TSK-11 scores between groups and across 4 time points (before preoperative treatment, after preoperative treatment, 6 months post-ACL reconstruction, and 12 months post-ACL reconstruction). Correlations determined the association of kinesiophobia levels with other clinical measures. Presurgery TSK-11 scores were significantly higher in noncopers than in potential copers. Postsurgery, no group differences existed. TSK-11 scores in both groups decreased across all time points; however, TSK-11 scores decreased more in noncopers in the interval between presurgery and postsurgery. In noncopers, the decreases in TSK-11 scores from presurgery to postsurgery and after surgery were related to improvements in the Knee Outcome Survey activities of daily living subscale, whereas the association was only present in potential copers after surgery. Kinesiophobia levels were high in both noncopers and potential copers preoperatively. Restoration of mechanical knee stability with surgery might have contributed to decreased kinesiophobia levels in noncopers. Kinesiophobia is related to knee function after surgery, regardless of preoperative classification as a potential coper or noncoper.

Clinical Examination Results in Individuals With Functional Ankle Instability and Ankle-Sprain Copers

Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited. To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings. Cross-sectional study. Sports medicine research laboratory. Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78). Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded. Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM. Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05). Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.

Role of External Prophylactic Support in Restricting Accessory Ankle Motion after Exercise

To both prevent and accelerate recovery and return-to-play from ankle sprains, clinicians frequently employ the use of external prophylactic support (EPS), such as taping and bracing, to provide mechanical support to the ankle joint. While common practice clinically, research has been inconclusive in demonstrating the effectiveness of EPS in restricting accessory motion (laxity) throughout activity, as well as its efficacy in restricting laxity in patients with complaints of ankle instability, and patients with a history of ankle sprain. The purpose of this study was to investigate the effectiveness of EPS type (None, Tape, Brace) on ankle laxity before and after exercise in subjects with varying degrees of previous ankle injury. Ankles from 24 participants (age, 20.6 ± 1.6 years; height, 173.6 ± 8.3 cm; mass, 72.8 ± 12.2 kg) were placed into one of three groups: healthy control (CON), potential coper (COP), and functionally unstable (UNS). Ankle laxity was assessed using an ankle arthrometer at 4 points in time; prior to EPS application, immediately following EPS application, following a 20-minute functional exercise protocol with EPS, and following removal of EPS. Peak ankle anterior displacement (ANT), inversion rotation (INV), and eversion rotation (EVR) were compared between groups and across conditions using a three-way ANOVA. Taping and bracing each decreased laxity from pre-application to pre-exercise and post-exercise. Tape provided greater restriction post-exercise in inversion and eversion rotation. Additionally, the UNS group demonstrated significantly greater anterior displacement post-exercise following removal of the brace compared to other groups. Compared to pre-application and post-removal, EPS significantly decreased ankle laxity before and after physical activity, with taping providing better restriction in inversion and eversion rotation throughout exercise. Following EPS removal, bracing revealed a greater increase in post-exercise laxity in subjects with ankle instability, suggesting tape may be more beneficial for controlling laxity in these patients.

Anterior cruciate ligament tears: what we already know

We enjoyed reading the systematic review by Delince and Ghafil [1]: it provides a refreshing picture of different approaches for the management of anterior cruciate ligament (ACL) injuries. We are in agreement with Delince and Ghafil [1] and respectfully point out some features that have become manifest over the course of the last 20 years. The authors stated that surgical reconstruction is not required in all patients with torn ACL and that it is possible to return to sports activities without surgery. In our opinion, the main indication for surgery is the functional instability (i.e. a symptom), and not the laxity (i.e. a sign), produced by a torn ACL. Indeed, the laxity in the anteroposterior plane is not necessarily correlated with instability [4]. The will of a patient to continue to participate in highlevel sport is not in itself an indication for surgery [6]. Given the lack of reliable predictors of instability, identifying which knees will become symptomatic (i.e. unstable), we consider surgery only after failure of a 6to 12-week period of intensive rehabilitation with hamstring strengthening and proprioception training. We proposed this strategy about 15 years ago, highlighting the critical role of the hamstrings to control the forward motion of the tibia in the flexed knee [5]. In 2003, we refreshed these concepts, reporting that the effectiveness of early ACL reconstruction to prevent or slow down the onset of degenerative changes had not yet been proven [4]. Indeed, the studies supporting the misconception that ACL reconstruction slows down or stops the onset of degenerative joint disease were biased, as the entry criterion was just complete the tear of the ACL, not symptomatic instability. According to the ‘‘rule of thirds’’ [7] for patients with an ACL tear (one-third does badly, one-third does well, and one-third does well if they modify their activities and badly if they continue with potentially injurious activities), two-thirds of included patients in studies where the indication for surgery was the tear of the ACL (and not the instability caused by such tear) would not have needed reconstruction. Other authors, strongly disagreeing with our opinion, stated that performing a reconstruction only after failure of rehabilitation and the experience of giving way episodes is associated with a poor result [4]. These authors believe that ACL reconstruction is able to prevent knee degeneration, and only a small subset of patients, less than one-third, would not need surgery. Thus, patients with an acute ACL tear, particularly those participating in athletics or other activities that require twisting or turning activities, should undergo surgery as early as possible to prevent further injuries, such as meniscus tears and articular cartilage damage. Finally, they implied that our management regimen was below par and stated that we should perform a proper care early after an ACL injury to provide superior results to our patients. However, 5 years later, Hurd et al. [3] reported that 42 % of 345 patients with an ACL injury could be managed, in the early post-injury phase, with rehabilitation only, and 72 % of these ‘‘potential copers’’ successfully returned to pre-injury sports activities in the short-term. Finally, only 59 % of patients who returned to high level of sports activity decided to have an ACL reconstruction. Subsequently, Frobell et al. [2], in an elegant and controversial randomised controlled trial, demonstrated the effectiveness of conservative management comparing structured rehabilitation plus early ACL reconstruction N. Maffulli (&) M. Loppini J. B. King Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK e-mail: n.maffulli@qmul.ac.uk

Identifying Individuals With an Anterior Cruciate Ligament-Deficient Knee as Copers and Noncopers: A Narrative Literature Review

Narrative literature review. First, to explore the differences and outcomes between individuals who have had anterior cruciate ligament (ACL) reconstruction and those who did not undergo surgical intervention, following a tear of the ACL. Second, to review the evidence related to the ability to identify individuals who may or may not need surgery after an ACL rupture. Finally, to describe the differences between copers and noncopers. ACL rupture may result in increased tibiofemoral laxity and impaired neuromuscular function, which ultimately may lead to knee instability and dysfunction. Individuals who opt to choose surgery due to these changes may be defined as "noncopers." Conversely, those individuals who have an ACL-deficient knee without functional impairment and instability and successfully resume preinjury activity levels without surgical intervention may be defined as "copers." An electronic search was conducted up to April 2011, using medical subject headings and free-text words. The subject-specific search was based on the terms "anterior cruciate ligament reconstruction versus conservative treatment," "copers," "noncopers." A similar percentage of copers and noncopers return to sporting activity. Three papers used an algorithm and screening examination involving individuals with ACL injuries. Evidence suggests that, as opposed to copers, noncopers have deficits in quadriceps strength, vastus lateralis atrophy, quadriceps activation deficits, altered knee movement patterns, reduced knee flexion moment, and greater quadriceps/hamstring cocontraction. ACL screening examination showed preliminary evidence for detecting potential copers. Objective differences exist between copers and noncopers. Individuals with ACL injury should be informed of the possibility of good knee function following a nonoperative rehabilitation program.

A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury

Prospective cohort study without a control group. Firstly, to present our 5-week progressive exercise therapy program in the early stage after anterior cruciate ligament (ACL) injury. Secondly, to evaluate changes in knee function after completion of the program for patients with ACL injury in general and also when classified as potential copers or noncopers, and, finally, to examine potential adverse events. Few studies concerning early-stage ACL rehabilitation protocols exist. Consequently, little is known about the tolerance for, and outcomes from, short-term exercise therapy programs in the early stage after injury. One-hundred patients were included in a 5-week progressive exercise therapy program, within 3 months after injury. Knee function before and after completion of the program was evaluated from isokinetic quadriceps and hamstrings muscle strength tests, 4 single-leg hop tests, 2 different self-assessment questionnaires, and a global rating of knee function. A 2-way mixed-model analysis of variance was conducted to evaluate changes from pretest to posttest for the limb symmetry index for muscle strength and single-leg hop tests, and the change in scores for the patient-reported questionnaires. In addition, absolute values and the standardized response mean for muscle strength and single-leg hop tests were calculated at pretest and posttest for the injured and uninjured limb. Adverse events during the 5-week period were recorded. The progressive 5-week exercise therapy program led to significant improvements (P<.05) in knee function from pretest to posttest both for patients classified as potential copers and noncopers. Standardized response mean values for changes in muscle strength and single-leg hop performance from pretest to posttest for the injured limb were moderate to strong (0.49-0.84), indicating the observed improvements to be clinically relevant. Adverse events occurred in 3.9% of the patients. Short-term progressive exercise therapy programs are well tolerated and should be incorporated in early-stage ACL rehabilitation, either to improve knee function before ACL reconstruction or as a first step in further nonoperative management. Therapy, level 2b.

Comparison of Involved and Uninvolved Quadriceps Strength Before and After ACL Reconstruction

Quadriceps muscle weakness is common after ACL rupture. To discriminate appropriate rehabilitation potential, patients with ACL deficient knees are classified by a screening exam into 2 groups- potential copers (PC) and noncopers (NC). Quadriceps strength deficits can exceed 20% at 6 months post ACL reconstruction (ACLR). The magnitude of quadriceps weakness appears to lessen with time, but most research suggests that deficits are apparent between the injured and the uninjured limb years following reconstruction. PURPOSE: The purpose of this study is to evaluate quadriceps strength symmetry in PC and NC over 4 different time periods (pre-perturbation, post perturbation, 6 months post (ACLR) and 12 months post ACLR). METHODS: Thirty-six highly active subjects with an acute, unilateral ACL tear who participated regularly in level I or II activities were screened following an injury to the index limb and classified as a PC (n=21) or NC (n=15). Quadriceps strength testing was assessed during a maximum voluntary isometric contraction (MVIC) using isometric dynamometer. Perturbation training was administered outlined by Fitzgerald et al. Repeated measures ANOVA were used to assess the differences and changes in quadriceps strength in PC and NC. Post hoc tests were used to determine where the differences occurred. Statistical analysis was performed with SPSS 17. All statistical significance levels were set at p < 0.05. RESULTS: No difference was seen between the two groups over time (p=0.508). A time*limb interaction was found (p< 0.001). Significant differences were found between limbs at pre-intervention (p<0.001) and post-intervention (p=0.008). No significant differences between limbs occurred 6 months ACLR (p=0.511) and 12 months ACLR (p=0.362). The strength of the uninvolved quadriceps did not change over time (p=0.080). A significant increase in strength of the involved quadriceps was found over time (p<0.001. CONCLUSION: Our results show that six and twelve months after ACLR, the strength between the involved and the uninvolved quadriceps is similar. The combination of perturbation training pre-operatively and aggressive quadriceps strengthening post-operatively can restore quadriceps strength symmetry following ACL reconstruction. Funded by the National Institutes of Health (R01HD037985-6).

Functional tests should be accentuated more in the decision for ACL reconstruction

A high pre-injury activity level, the desire of the patient to continue pivoting sports and fear of future give-way episodes are considered the most significant factors affecting the decision to perform anterior cruciate ligament reconstruction. However, since the functional status of the knee at the time of surgery affects the final outcome, assessments of knee function should be considered in the decision making for surgery. Individuals with anterior cruciate ligament injury can be classified as potential copers or non-copers from an existing screening examination. The purpose of this study was to investigate whether the functional tests incorporated in the original screening examination could contribute to explain those who later go through anterior cruciate ligament reconstruction and to examine whether changes to the content or the time of conducting the screening examination (before or after ten sessions of exercise therapy) could improve its explanatory value. One-hundred and forty-five individuals were included and prospectively followed for 15months, after where 51% had gone through anterior cruciate ligament reconstruction and 49% were managed non-operatively. The only significant baseline differences between those who later went through anterior cruciate ligament reconstruction and those who were non-operatively treated were that those who had surgery were younger and had a higher activity level (P<0.05). Regression analyses revealed that the explanatory value for those who later went through anterior cruciate ligament reconstruction significantly improved when the original screening examination was considered compared to only age, activity level and give-way episodes. Changes to the content further improved the explanatory value, with quadriceps muscle strength as the single variable with the highest impact. Finally, conducting the screening examination after ten sessions of progressive exercise therapy gave the overall highest explanatory values, suggesting that the screening examination should be conducted subsequent to a short period of rehabilitation to inform decision making for anterior cruciate ligament reconstruction.

Anterior Cruciate Ligament—Deficient Potential Copers and Noncopers Reveal Different Isokinetic Quadriceps Strength Profiles in the Early Stage after Injury

Background Isokinetic muscle strength testing using the peak torque value is the most frequently included quadriceps muscle strength measurement for anterior cruciate ligament (ACL)—injured subjects. Purpose and Hypotheses The purpose of this study was to investigate quadriceps muscle performance during the whole isokinetic curve in subjects with ACL deficiency classified as potential copers or noncopers and to investigate whether these curve profiles were associated with single-legged hop performance. We hypothesized that quadriceps muscle torque at other knee flexion angles than peak torque would give more information about quadriceps muscle strength deficits. Furthermore, we hypothesized that there would be significant torque differences between potential copers and noncopers and a significant relationship between angle-specific torque values and single-legged hop performance. Study Design Cross-sectional study; Level of evidence, 3. Methods Seventy-six individuals with a complete unilateral ACL rupture within the last 3 months were included. The subjects were classified as potential copers and noncopers. Isokinetic quadriceps muscle tests were performed at 60 deg/s. Mean torque values were calculated for peak torque as well as for specific knee flexion angles. The 1-legged hop and the 6-m timed hop tests were included, and symmetry indices were used. Results The peak torque value did not identify the largest quadriceps muscle strength deficit. Rather, these were established at knee flexion angles of less than 40°. There were significant differences in angle-specific torque values between potential copers and noncopers (P < .05). Moderate to strong associations were disclosed between angle-specific torque values and single-legged hop performance, but only for noncopers (r ≥ .32-.58). Conclusion Angle-specific quadriceps muscle torque values of less than 40° of knee flexion provide more information on the quadriceps strength deficits after ACL injury than the commonly used peak torque values. Interpretation of the isokinetic curve profiles seems to be of clinical importance for the evaluation of quadriceps muscle performance after ACL injury.

Knee Function Following Perturbation Training In Potential Copers And Noncopers

Knee Function Following Perturbation Training In Potential Copers And Noncopers

Individuals With an Anterior Cruciate Ligament-Deficient Knee Classified as Noncopers May Be Candidates for Nonsurgical Rehabilitation

Prospective cohort study. First, to classify a group of individuals with an anterior cruciate ligament (ACL)-deficient knee as potential copers or potential noncopers, based on an established screening examination. Second, to prospectively follow a cohort of individuals with an ACL injury and characterize the nonoperatively treated subjects as true copers and true noncopers 1 year after injury, and evaluate the outcomes in operatively treated individuals 1 year after ACL reconstruction. Finally, to calculate the predictive value of the screening examination based on a 1-year follow-up of the group of subjects with ACL tears treated nonoperatively. A screening examination has been developed for early classification of individuals with ACL injuries. Potential copers have successfully been identified as rehabilitation candidates and have shown that they are able to continue preinjury activities without ACL reconstruction (true copers). However, the potential of individuals identified as noncopers to become true copers has not been studied. One hundred and twenty-five subjects with ACL injury were evaluated using a screening examination consisting of 4 single-legged hop tests, the Knee Outcome Survey activities of daily living scale, the global rating of knee function, and the numbers of episodes of giving way. Knee laxity measurements, the international knee documentation committee subjective knee form (IKDC2000), and return to sport were included as outcome measurements. Thirty-seven percent (n = 46) of the subjects with ACL injury were classified as potential copers at the screening examination. Of the 102 subjects examined at follow-up, 51% (n = 52) had undergone nonoperative treatment. Sixty-five percent (n = 34) of the nonoperated subjects were classified as true copers at the 1 year follow-up. Among the potential copers, 60% were true copers, while 70% of the subjects initially classified as potential noncopers were true copers at the 1 year follow-up. The positive predictive value for correctly classifying true copers at the screening examination was 60% (95% confidence interval: 41%-78%), while the negative predictive value was 30% (95% confidence interval: 16%-49%). A majority (70%) of subjects classified as potential noncopers were true copers after 1 year of nonoperative treatment. Individuals with nonoperative treatment and ACL reconstruction showed excellent knee function and were highly active at the 1 year follow-up. The prognostic accuracy of this screening examination for correctly classifying true copers was poor.

6 Month Outcome Comparison of a Potential Coper and Non-coper

PURPOSE: To determine the effects of perturbation training on a non-coper and potential coper. METHODS: Quadriceps strength was tested using burst superimpositioning. Subjects were screened (single hop and timed hop, self-report questionnaires (KOS-ADL and global rating (GR) of perceived function), and number of knee give ways). One subject (PC) passed the screen (>80% on timed hop compared to uninvolved leg, >80% KOS, >60% GR, less than 1 episode of giving way) and the other (NC) failed due to 3 episodes of give-way. Both underwent 10 perturbation training sessions and a followup functional test, including tests in the screen plus triple and cross-over hops. Subjects could return to sport if they presented with >90% quadriceps index (QI) and each hop test (involved/uninvolved), and >90% KOS-ADL and GR. Subjects returned at 6 months for a repeat functional test. RESULTS: Post-training functional test: PC passed RTS criteria. NC passed criteria for the single and timed hop, and increased his QI, KOS-ADL and GR. 6-month follow-up: Both subjects passed all RTS criteria. Symmetry values improved for each (PC 98% - 112% in hops; NC 96% - 102% in hops). NC had a greater improvement from screen to follow-up in involved MVIC (NC +20%, PC +6%), single hop (NC +11%, PC +5%), KOS-ADL (NC +9%, PC +6%) and GR (NC +35%, PC +6%). Sport participation: Subjects were issued a de-rotational brace for use during sport. PC returned to skiing and recreational basketball, however he did not feel stable playing soccer and opted for surgery. Without first passing RTS, NC returned to basketball involving cutting, jumping, acceleration and deceleration, with only one episode of giving-way (not braced). CONCLUSIONS: The greater improvement in KOS-ADL and GR of NC may be due to a ceiling effect for PC on these measures. The greater increases in the functional scores on the single hop and MVIC are most likely due to the low level of the patient at the time of screening. The values of the timed hop are similar in both subjects (PC 1.8s, NC 1.84s) NC achieved symmetry between legs, though it took longer than PC. The instability experienced by non-copers may be controlled with a de-rotational brace and symmetrical performance on hop testing, with return to high level sports. These patients may need a longer period of training to achieve this functional status.

A 10-Year Prospective Trial of a Patient Management Algorithm and Screening Examination for Highly Active Individuals with Anterior Cruciate Ligament Injury

Background A treatment algorithm and screening examination have been developed to guide patient management and prospectively determine potential for highly active individuals to succeed with nonoperative care after anterior cruciate ligament rupture. Objective To prospectively characterize and classify the entire population of highly active individuals over a 10-year period and provide final outcomes for individuals who elected nonoperative care. Methods Inclusion criteria included presentation within 7 months of the index injury and an International Knee Documentation Committee level I or II activity level before injury. Concomitant injury, unresolved impairments, and a screening examination were used as criteria to guide management and classify individuals as noncopers (poor potential) or potential copers (good potential) for nonoperative care. Results A total of 832 highly active patients with subacute anterior cruciate ligament tears were seen over the 10-year period; 315 had concomitant injuries, 87 had unresolved impairments, and 85 did not participate in the classification algorithm. The remaining 345 patients (216 men, 129 women) participated in the screening examination a mean of 6 weeks after the index injury. There were 199 subjects classified as noncopers and 146 as potential copers. Sixty-three of 88 potential copers successfully returned to preinjury activities without surgery, with 25 of these patients not undergoing anterior cruciate ligament reconstruction at the time of follow-up. Conclusion The classification algorithm is an effective tool for prospectively identifying individuals early after anterior cruciate ligament injury who want to pursue nonoperative care or must delay surgical intervention and have good potential to do so.