Reabilitação LCA 2

Rehabilitation Practice Patterns following Anterior Cruciate
Ligament Reconstruction: A Survey of Physical Therapists

Elliot M. Greenberg PT, PhD†, Eric T. Greenberg PT¥, Jeffrey Albaugh PT†, Eileen Storey BS*,
Theodore J. Ganley MD*†
† Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia,

Philadelphia, PA
¥ New York Institute of Technology, Department of Physical Therapy, Old Westbury, NY

Downloaded from www.jospt.org at La Trobe University on May 26, 2018. For personal use only. No other uses without permission.
*Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA
*Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
Conflict of Interest Statement:

Copyright © ${year} Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
We, the authors, affirm that we have no financial or commercial affiliations related to the
performance or outcome of this manuscript.
Grant Support
There was no grant support for this study
IRB Statement:
Journal of Orthopaedic & Sports Physical Therapy®
Institutional Review Board of The Children’s Hospital of Philadelphia approved this study.
Protocol #: 16-013163
Address all correspondence to:

Elliot M. Greenberg, PT, PhD
Sports Medicine and Performance Center at
The Children’s Hospital of Philadelphia
Pediatric and Adolescent Specialty Care Center Bucks County
500 W. Butler Ave.
Chalfont, PA 18914 
Email: greenberge@email.chop.edu
1
1 Study Design: Cross-Sectional Survey
3 Background: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an
4 intensive course of post-operative rehabilitation. Although guidelines outlining evidence-based
5 rehabilitation recommendations have been published, the actual practice patterns of physical
6 therapists are unknown.

8 Objectives: To analyze the current landscape of clinical practice as it pertains to rehabilitation
9 progression and the use of time and objective criteria following ACLR.
10
11 Methods: An online survey was distributed to members of the orthopaedics, sports and private
12 practice sections of the American Physical Therapy Association (APTA) between January and
13 March 2017.
14
15 Results: 1074 responses were analyzed. Supervised physical therapy was reported to last ≤5
16 months by 56% of the sample. The most frequent time frame for activity progression was: 3-4
17 months (58%) for jogging, 4-5 months (51%) for modified sports activity and 9-12 months
18 (40%) for unrestricted sports participation. Greater than 80% of the sample reported using
19 strength and functional measures during rehabilitation. Of those that assessed strength, 56%
20 used manual muscle testing as their only means of strength testing. Single limb hop testing
21 (89%) was the most frequently reported measure utilized to begin modified sports activity.
22 Performance criteria for strength and functional tests varied significantly across all phases of
2
23 rehabilitation. Of the 45% that reported utilizing patient reported outcome measures, only a
24 small proportion of those concerned fear or athletic confidence scales (10%).
25
26 Conclusions: Considerable variation exists amongst APTA members with regards to
27 rehabilitation following ACLR. This variability in practice may contribute to suboptimal
28 outcomes and confusion among practitioners and patients.

29
30 Key Words: Anterior Cruciate Ligament, ACL, postoperative rehabilitation, physical therapy,
31 physical therapy survey
32
3
33 Anterior cruciate ligament (ACL) injuries commonly occur during sports requiring jumping,
34 cutting, and pivoting. Although select individuals may attempt conservative management,25 the
35 vast majority undergo reconstructive surgery, with upwards of 300,000 ACL reconstructions
36 (ACLR) being performed annually in the United States alone.12 Despite continued
37 advancements in surgical techniques and rehabilitation, outcomes following ACLR may be less
38 than desirable, with only 33% of athletes returning to sports within one year after surgery,5 and
39 37% never returning to their prior level of sports participation.4 Additionally, and perhaps more
40 alarmingly, up to 30% of individuals may incur a second ACL injury,23 resulting in higher health
41 care costs and increased disability.
42 Postoperative rehabilitation can play a vital role in successful recovery following ACLR by
43 optimizing function and reducing the risk of a second ACL injury.21, 38 Historically, rehabilitation
44 progression following ACLR relied heavily on time based standards, respecting the processes of
45 graft maturation and physiological healing.17 However, rehabilitation recommendations have
46 evolved over time and most contemporary protocols recommend a more comprehensive decision
47 making framework, utilizing the fusion of time and objective functional performance criteria to
48 guide postoperative progression.1, 7, 26, 27 Nonetheless, a recent systematic review found that
49 >70% of published studies excluded functional measures in return to play decision making,
50 revealing a discrepancy between current recommendations for best practice and published
51 literature.6 Additionally, literature analysis reveals significant variation in published
52 rehabilitation protocols and inconsistent recommendations of specific performance measures or
53 criteria for decision making regarding activity progression throughout all phases of
54 rehabilitation.32, 43 This discordance contributes to a complicated practice environment, which
55 may lead to confusion or inconsistent clinical practice patterns among physical therapists (PTs)
4
56 treating patients after ACLR. Thus, the purpose of this study is to understand the current
57 landscape of clinical practice among members of the American Physical Therapy Association
58 (APTA), as it pertains to rehabilitation decision making and the use of objective tests in guiding
59 activity progression following ACLR. The findings will be analyzed within the context of
60 current literature, in order to determine if clinical practice is reflective of up-to-date
61 recommendations and scientific evidence. Additionally, the relationship of clinical practice

62 patterns to clinician characteristics will be analyzed in order to understand some of the
63 underlying factors that may be related to individual clinical decision making.
64 Methods
65 Survey Development
66 A team of clinicians (3 physical therapists and 1 orthopaedic surgeon) highly experienced in
67 managing patients following ACLR, collaborated to develop the electronic survey using
68 REDCap electronic data capture tools, hosted at the Children’s Hospital of Philadelphia.20 The
69 initial phase of development consisted of identification of key rehabilitation transitional phases

70 and preliminary question development guided by previously published reports and clinical
71 expertise.32-34 Due to differences that may exist in rehabilitation and activity progression based
72 upon patient characteristics such as age, activity level, surgery type, graft type and concomitant
73 injuries, it was determined that the questionnaire should be grounded utilizing a standardized
74 case vignette representative of a typical patient encountered within a sports or orthopaedic
75 setting. Survey participants were asked to answer the questions in the survey based upon their
76 typical treatment of the following patient “Your patient is a 17-year-old female soccer player
77 who underwent ACL reconstruction using a hamstring autograft. There were no concomitant
5
78 injuries and she is having an uncomplicated postoperative recovery. Her goal is to return to
79 soccer competition at the collegiate level upon full recovery."
80 Each survey participant was instructed to answer all questions that related to their clinical
81 practice of patients after ACLR. In order to be time efficient, the electronic survey incorporated
82 the use of branching logic, which propagated specific follow-up questions only if pertinent
83 responses were selected in previous questions; thus the total number of questions answered by
84 each participant varied based upon the respondents’ individual practice patterns. The survey
85 consisted of 6 sections: 1) Clinician demographics and clinical practice information, 2) Clinical
86 decisions related to jogging, 3) Clinical decisions related to modified sports activity (e.g.
87 agilities, sports-specific drills/skills), 4) Return to unrestricted sports 5) Use of injury prevention

88 programs and 6) Use of functional bracing upon return to sports.
89 The initial development team reviewed and tested the survey amongst themselves for format,
90 inclusivity of content, clarity and survey functionality. After all initial revisions were made, the
91 survey was pilot tested among a group of 5 physical therapists and 3 orthopaedic surgeons. All
92 suggestions were considered and modifications to the survey were made after consultation
93 among all authors. During pilot testing, the survey took approximately 4-7 minutes to complete.
94 The complete survey instrument is available to view online. (eAppendix)
95 Survey Distribution
96 Physical therapists were recruited through email invitations sent to members of the APTA
97 Orthopaedic and Sports Sections. In addition, participation was solicited from members of the
98 APTA Private Practice Section via an embedded link within their electronic newsletter. These
99 groups were selected based upon likelihood of treatment of the intended patient population. A
100 single reminder email was sent near the halfway point to Sports Section members only. All other
6
101 possible subjects received a single invitation only at the outset of the study. The invitation
102 provided a brief study description and encouraged PTs who actively treat patients after ACLR to
103 participate. Interested participants clicked the electronic link connecting them to a more detailed
104 study description, which included eligibility criteria. Access to the survey was granted after
105 selecting “yes” to the question indicating their informed consent to participate. No identifying
106 information was collected on any of the subjects and thus participation was completely
107 anonymous. Survey responses were collected over a period of 2 months between January and
108 March 2017. This study received approval by all necessary Institutional Review Boards prior to
109 onset. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to
110 ensure the quality of reporting the findings of this study.16

111 Data Analysis
112 Data was analyzed using IBM SPSS, version 24.0 (IBM Corp, Armonk, New York). The
113 primary analysis involved use of descriptive statistics to summarize the distribution, frequency
114 and dispersion of respondents' responses. A secondary analysis utilizing chi-square was
115 conducted in order to determine whether relationships existed between clinician characteristics
116 indicative of advanced clinical proficiency (i.e. years of experience, volume of ACL patients
117 treated, and board certified specialist certification) and rehabilitation progression after ACLR.
118 These groups were operationally defined as follows: 1) Experienced versus less experienced
119 practitioners were those with either 16+ years of clinical experience or those with 0-4 years, 2)
120 High versus low volume were those treating >10 or those treating <5 ACLR per year, 3) Board
121 certified versus non-board certified were divided by those indicating possessing Orthopaedic
122 (OCS) or Sports (SCS) specialist certification. For dichotomous analysis, significance values
7
123 were set at p<0.05. For analysis with in which multiple comparisons were made, appropriate
124 Bonferroni correction was utilized to determine statistical significance.
125
126 Results
127 Survey Response
128 A total of 1084 survey responses were recorded, 10 responses were excluded from data analysis
129 (7 failed to consent and 3 were not licensed physical therapists). Therefore, a total of 1074
130 responses were included. Of these, 593 (55.2%) accessed the survey via Orthopaedic Section
131 email invitation while 403 (37.5%) accessed via the Sports Section. The remaining 78 (7.2%)
132 responses accessed the survey through other modes including the Private Practice Section
133 newsletter or word of mouth.
134 Respondents’ Profile
135 Demographic and professional characteristics of respondents are presented in TABLE 1. All but
136 one state (Rhode Island) were represented in the sample. Respondents were well distributed
137 across various years of clinical practice and volume of ACLR patients treated per year. Most
138 respondents primarily treated patients in a private practice (42.8%) or hospital based outpatient
139 facility (35.8%). Though nearly all of the respondents were members of the APTA (92.5%), half
140 were board certified in Orthopaedics or Sports Physical Therapy (52.5%).
141 Decision-making regarding activity progression
142 A large proportion of our sample (80.1%) indicated that progression of activity after ACLR was
143 largely a collaborative process with shared decision making between both the orthopaedic
144 surgeon and the physical therapist.
145 Time Criterion
8
146 “For the patient described, how long would your typical course of rehabilitation be? (i.e. How
147 long would you treat them within an office setting?)”
148 The length of supervised rehabilitation spanned from 1-3 months (15.6%) to 12 months (11.2%),
149 though the majority reported 4-5 months (40.6%) and 6-8 months (32.1%). There were
150 significant associations between length of rehabilitation and clinician characteristics detailed in
151 TABLE 2. Clinicians with less clinical experience, higher volumes of ACLR patients and OCS
152 or SCS certification indicated a longer overall duration of clinical care.
153 “I would typically allow the athlete in this example to begin [jogging, modified sports activity, or
154 unrestricted return to sports], at ______ months post-surgery?”
155 Response frequencies pertaining to transitional time points of jogging, modified sports activity,
156 and unrestricted return to sports are presented in TABLE 3. Nearly all PTs indicated that they
157 would initiate jogging between 2 and 5 months postoperatively, with the majority (58%)
158 reporting starting at 3-4 months. Modified sports activity (e.g. agility, coordination drills) was
159 most often initiated at 4-5 months (50.6%) and 6-7 months (31.6%). Progression to unrestricted
160 sports was reported to occur most frequently between 9-12 months postoperatively (39.8%),
161 however there was a much wider distribution of responses within this phase compared to the
162 other transition points.
163
164 Criterion Based Measures
165 Progression to Jogging, modified sports activity, and unrestricted return to sports
166 “Are there specific physical tests, examination findings, or criteria that you utilize in order to
167 assist in the decision to progress to [jogging, modified sports activity, or unrestricted return to
168 sports]?”
9
169 The most often reported criteria to initiate jogging and modified sports activity were knee
170 strength (91.6% and 80%, respectively), functional/balance tests (86.9% and 82.5%,
171 respectively), knee range of motion (80.3% and 61.9%, respectively), and degree of knee
172 effusion (70.6% and 59.6%, respectively). In regards to unrestricted return to sports, a small
173 majority of respondents (54.7%) indicated they did not require any additional testing for
174 progression. (FIGURE 1)

175
176 Knee Strength
177 Knee strength was often reported as a key component of determining readiness for activity
178 progression throughout all phases of rehabilitation. If a respondent included knee strength as part
179 of their assessment, additional data was gathered pertaining to method of testing and is
180 represented in FIGURE 2. Of those that utilized knee strength to initiate running and modified
181 sports activity, manual muscle testing (MMT) was the most common response, accounting for
182 80.6% (n=793/984) and 74.3% (n=638/859), respectively, and 54.9% (n=472/859) utilized at
183 least one method of objective measure (isometric or hand held dynamometry (HHD), isokinetics,
184 or repetition maximum testing). Of those that utilized MMT to begin modified sports activity,
185 56.1% (n=358/638) reported using MMT as their only means of strength assessment, where the
186 remaining 43.9% (n=280/638) used it in adjunct to more objective modes.
187 High volume practitioners and certified specialists were more likely to utilize objective strength
188 measures, while low volume practitioners and non-certified specialists were more likely to rely
189 solely on MMT (X2=22.088, P< 0.001 and X2=7.804, P=0.005). There was no association
190 between the amount of clinician experience and type of strength measure (X2=0.264, P= 0.608).
191 Quadriceps limb symmetry index (LSI) standards were recorded from those respondents that
192 utilized isometric or HHD, isokinetic, or repetition maximum testing for both the jogging and
10
193 modified sports activity phases (FIGURE 3). Although there was significant variation in
194 responses, a quadriceps LSI of >80% was the most commonly cited criteria to initiate jogging,
195 regardless of testing mode. However, when progressing to modified sports activity, those who
196 performed repetition maximum (RM), isometric or HHD testing more often required more
197 stringent criteria (>90% LSI) than those that utilized isokinetic assessments (>85% LSI).
198
199 Functional Testing
200 The lateral step down test (60.8%), Y Balance or Star Excursion Balance Tests (YBT/SEBT)
201 (55.6%) and Functional Movement Screen© (FMS) (31.4%) were the most frequently cited
202 functional tests utilized to initiate jogging. To determine readiness for modified sports activity,
203 single limb hop tests were used by the majority of respondents (89.2%), followed by the
204 YBT/SEBT (48.8%) and drop vertical jump (DVJ) (39.5%). (TABLE 4) Of those that utilized
205 single limb hop testing, 79.4% reported using at least two types of hop tests, with the single hop
206 (89.4%) and triple hop (80%) used most frequently (TABLE 5). Approximately 60% of the
207 sample required an LSI of ≥90% for progression to modified sports activity, with the remainder
208 of the sample reporting an LSI of 75% to 85% being acceptable.
209
210 Despite being one of the more common responses, cutoff criterion varied for the YBT/SEBT and
211 FMS. Of those respondents that will perform the YBT or SEBT to initiate jogging, 42% will
212 require an anterior reach distance of less than 4cm, while 72.6% require a between limb
213 composite reach score of >90%. Similarly, of those that reported utilizing the FMS, 51.9%
214 utilize the overall score, 61.1% stress the performance on isolated movements, and 82.3% rely on
215 side-to-side movement symmetry during the unilateral movements.
11
216 High volume practitioners were more likely to use the YBT/SEBT (X2=10.895, P=0.001) and
217 DVJ (X2=14.576, P<0.001). Less experienced clinicians were also more likely to utilize the
218 YBT/SEBT (X2=17.46, P<0.001). (FIGURE 4)
219
220
221 Patient Reported Outcome Measures

222 Patient Reported Outcome Measures (PROMs) were utilized by 45.3% of PTs for progression to
223 modified sports activity. Of those utilizing these tools, the Lower Extremity Functional Scale
224 was most widely reported (39.2%), while scales related to fear or athletic confidence were less
225 commonly reported (9.7%). (FIGURE 5) There were no significant associations of clinician
226 characteristics and the use of PROMs.
227
228 Post-Rehabilitation Factors: Injury Prevention Programs and Functional Bracing
229 Although most PTs (74.9%) recommend injury prevention programs after ACLR, high volume
230 practitioners (X2=20.266, P<0.001) and certified specialists (X2=4.007,P=0.045) were more likely
231 to incorporate them into their plan of care. There was no clear consensus in program preference
232 with most utilizing Santa Monica PEP (31.3%), FIFA 11+ (21.4) or an individually adapted
233 program (29.7%). With regards functional bracing, overall 41.1% of PTs favored their use upon
234 return to sports, with certified specialists being less likely (X2=4.767, P=0.029) to recommend
235 them.
236
237 Discussion
238 The results of this survey provide a detailed description of physical therapy practice patterns for
239 postoperative care of young athletes after ACLR. One of the most noticeable findings was the
12
240 degree of variability in clinical testing and decision making, particularly within the later phases
241 of rehabilitation during the transition back to sports activity. Although surprising, this result may
242 reflect the lack of well-defined clinical evidence to guide practice, as currently there is no
243 consensus of an ideal postoperative rehabilitation program.15, 43
244 The incorporation of time-based criteria into ACLR rehabilitation protocols has been advocated
245 based upon biological features of graft strength, stiffness, and strength of fixation.44 The results
246 of this survey show that agreement regarding time-based criteria decreased as the rehabilitation
247 course progressed. While a small majority (defined as >50% of the sample) of PTs agreed that
248 jogging and return to modified sports activity should occur between 3-4 and 4-5 months,
249 respectively, agreement for progression to unrestricted return to sports was more dispersed.
250 These results likely reflect the complexity of decision making in the later phases of
251 rehabilitation, which may include type of sport and individual patient specific factors. However,
252 this finding may also reflect the variability in guidelines, with published reports demonstrating
253 similar variation, calling for this transition between months 4 and 9+ postoperatively.1, 24, 44
254 Interestingly, 88.3% of the sample indicated a typical duration of supervised rehabilitation lasted
255 ≤ 8 months, while 45.1% indicated they do not recommend unrestricted return to sports until 9-
256 12+ months. These findings imply that there may be a long gap between the discontinuation of
257 supervised rehabilitation and return to activity. While other rehabilitation professionals, such as
258 athletic trainers, may be able to advise athletes during this period, a recent survey demonstrated
259 that only 37% of public secondary schools provide full-time athletic training services.37 As a
260 result, most patients would be responsible for self-managing this advanced phase of recovery
261 without any professional supervision. The subgroup analysis revealed that newer clinicians, high
262 volume practitioners, and certified specialists advocated for a longer duration of supervised care.
13
263 One possible explanation for this finding is that these groups are more cognizant of
264 contemporary ACLR rehabilitation models, which call for more prolonged time-frames prior to
265 returning to sports,8, 15, 24 resulting in the desire for a longer duration of supervised rehabilitation
266 Alternatively, this finding may also be explained by more experienced clinicians having
267 established a network of community-based alternative practitioners (e.g. athletic trainers,
268 personal trainers, coaches) to entrust supervision of late phase rehabilitation for these athletes.
269 Future research is necessary to explore these observations and understand the driving force
270 behind time-based decisions amongst these groups of practitioners.
271 There was clear agreement (>80% of sample responses) on the importance of a multi-
272 dimensional approach to informed decision making after ACLR, utilizing physical measures
273 such as strength, lower extremity function, and dynamic stability, which aligns with the
274 recommendations in published literature.3, 15, 43 Despite global agreement on these principles, PTs
275 varied in the mode and interpretation of these measures. For example, greater than 90% of the
276 sample incorporated thigh muscle strength assessment, however testing procedure and LSI
277 criterion values varied considerably across respondents. Of particular note, more than half of the
278 sample indicated they utilized MMT as a solitary strength measure to progress to modified sports
279 activity. Although MMT is a basic skill universally applied across all areas of rehabilitation,
280 MMT may lack the sensitivity to detect residual strength deficits that may be present at this
281 phase of recovery,9 leading to poorly informed decision making. The subgroup analysis
282 indicated high volume practitioners and certified specialists were more likely to incorporate
283 objective strength measures. This may reflect a higher level of training or a greater appreciation
284 for the precision offered from these more sensitive measures of strength. Conversely, the
285 decreased use of these measures among PTs who treat a low volume of patients after ACLR
14
286 might be explained by an economic cost/benefit analysis as additional equipment costs,
287 additional training, and time requirements spent on performing more involved testing procedures
288 may not be justified from a business perspective.
289 Variability continues to perpetuate when analyzing LSI criteria identified to progress through the
290 various phases of rehabilitation. Independent of testing mode, PTs were unable to reach a
291 majority (>50% agreement) on the required strength LSI for functional advancement. This
292 finding may be reflective of a lack of clear evidence to guide practice, noting the large variability
293 of LSI thresholds seen within the published literature.1, 32, 39-41, 44 Alternatively, research has
294 shown a significant lag time exists for new evidence to trickle down into routine clinical practice,
295 and that an individual clinician’s willingness to adapt their practice to this evidence varies.11, 13, 35
296 Thus, these findings could be explained by variability in individual adoption of contemporary
297 strength LSI recommendations. This hypothesis may explain why a large proportion of PTs
298 indicated utilizing cutoff values of <90% LSI to return to sports related activities, while many
299 recently published reports advocate for >90% LSI.1, 6, 39, 40, 42, 43
300
301 Understanding the driving forces behind these findings is important, as this variation in clinical
302 practice may contribute to substandard outcomes after ACLR. While optimal thresholds for
303 strength requirements are unknown, evidence suggests that an LSI of <90% may increase the risk
304 of re-injury upon resumption of level 1 sports.19 Improving the use of objective strength testing,
305 along with implementing strategies to facilitate the adoption of standardized LSI requirements
306 among treating clinicians will lead to more empowered decision making at the time of return to
307 sports and improved ability to conduct comparative outcomes research.
15
308 Practice variation diminishes when it comes to the use of functional testing procedures with
309 nearly 90% of the sample reporting the use of single leg hop testing as part of their practice to
310 determine a patient’s readiness to begin modified sports activity. Since first appearing in the
311 literature in the early 1990’s, the battery of single limb hop tests described by Noyes et al36 have
312 been almost universally adopted as a necessary performance test for return to play decision
313 making after ACLR.15, 31 These hop tests are reliable, easy to administer, require minimal
314 equipment or physical space, and have demonstrated good discriminative accuracy and
315 predictive abilities.10, 29, 36 The consistency of this recommendation, along with the simplicity of
316 testing procedure may be the driving forces behind the level of agreement seen within our
317 results.
318 Interestingly, high volume practitioners and less experienced clinicians reported including more
319 novel measures of limb function, such as the YBT/SEBT or DVJ, in their test batteries. This
320 result may reflect a deeper appreciation of, or early adoption of, more current literature
321 recommendations that seek to include measures of functional limb control and movement quality
322 to improve recognition of performance deficits or risk factors for re-injury.18, 22, 43
323 Use of knee specific PROMs, such as the Knee Outcome Survey or International Knee
324 Documentation Committee scale, are often advocated to quantify functional deficits that may
325 impact a patient’s successful return to activity following ACLR.1, 14 Regrettably, less than half of
326 PTs in our sample reported using PROMs as part of their decision-making criteria to progress to
327 modified sports activity. Moreover, it has become clear that physical recovery alone is not
328 sufficient to ensure successful return to sports and many authors have emphasized the
329 importance of assessing psychological readiness and fear of re-injury.2, 14, 15, 28 Despite these
330 recommendations, just under 10% of our sample indicated incorporation of PROMs related to
16
331 fear or athletic confidence, neglecting the holistic framework highlighted within the
332 biopsychosocial approach of patient management.
333 Limitations
334 There are several limitations to this study that should be recognized. The survey questionnaire
335 was not previously validated and although efforts were made to ensure clarity and accurate
336 interpretation during development and pilot testing, individual variations in the interpretation of
337 questions may exist. Nearly all of our sample were members of the APTA, which may limit the
338 generalizability of our results to the larger population of non-member PTs. Due to this relative
339 homogenous trait of our population, it is possible that our findings may actually underestimate
340 the true degree of variability that does exist, if a more diverse group of PT’s, inclusive of APTA
341 non-members, participated in this study. Due to the electronic distribution methods and
342 anonymous nature of the survey, we were unable to account for emails that were undelivered,
343 unopened, or received in duplicate by members of more than one APTA section and thus, we are
344 unable to determine a true response rate. In an attempt to ensure as much honesty in participant
345 answers, this survey was anonymous and no information was collected regarding the individual,
346 which may have allowed some to access the survey more than once if they wished to. Lastly,
347 while we attempted to understand some of the driving forces behind clinical practice patterns
348 identified within the survey results, there were no questions related to the effects of third-party
349 payer regulations or other external influences on practice, and thus we cannot account for these
350 confounding variables.
351 Conclusion
352 This survey is the first to characterize the clinical practice patterns of PTs responsible for the
353 treatment of patients after ACLR. The results indicate there is a fairly large degree of variation
17
354 in rehabilitation progression amongst APTA members, particularly with regards to timing of
355 activity progression, strength assessment and use of PROMs. This pattern of inconsistency
356 escalated as the time from surgery increased. Physical therapists who treated a larger volume of
357 ACLR patients, more recent graduates and those with specialty certifications generally reported
358 clinical practice patterns that were more consistent with current best evidence.30, 31 Future
359 research should be directed towards understanding what factors contribute to this variability in
360 clinical approach, as such inconsistency may facilitate feelings of confusion among patients and
361 impact outcomes after ACLR.
362 Findings:
363 Physical therapists report a large degree of variation in rehabilitation practice patterns after
364 anterior cruciate ligament reconstruction (ACLR), particularly with regards to time, strength
365 assessment and use of standardized outcome measures.
366 Implications:
367 This variability in clinical practice standards may contribute to sub-optimal outcomes and
368 facilitate confusion among patients and families.
369 Caution:
370 These results should be interpreted with caution, as this sample represents only a small portion of
371 all licensed physical therapists who may be treating individuals after ACLR.
372
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380
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381 References
382 1. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current concepts for
383 anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop
384 Sports Phys Ther. 2012;42:601-614.
385 2. Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the
386 Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports
387 Health. 2015;7:224-230.
388 3. Ardern CL, Ekas G, Grindem H, et al. 2018 International Olympic Committee consensus
389 statement on prevention, diagnosis and management of paediatric anterior cruciate ligament
390 (ACL) injuries. Knee Surg Sports Traumatol Arthrosc. 2018;
391 4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament
392 reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports
393 Med. 2011;45:596-606.
394 5. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the preinjury level of competitive sport
395 after anterior cruciate ligament reconstruction surgery: two-thirds of patients have not returned
396 by 12 months after surgery. Am J Sports Med. 2011;39:538-543.
397 6. Barber-Westin SD, Noyes FR. Factors used to determine return to unrestricted sports activities
398 after anterior cruciate ligament reconstruction. Arthroscopy. 2011;27:1697-1705.
399 7. Barber-Westin SD, Noyes FR. Objective criteria for return to athletics after anterior cruciate
400 ligament reconstruction and subsequent reinjury rates: a systematic review. Phys Sportsmed.
401 2011;39:100-110.
402 8. Beischer S, Senorski EH, Thomee C, Samuelsson K, Thomee R. Young athletes return too early to
403 knee-strenuous sport, without acceptable knee function after anterior cruciate ligament
404 reconstruction. Knee Surg Sports Traumatol Arthrosc. 2017;
405 9. Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening
406 test? Clin Rehabil. 2005;19:662-667.
407 10. Bolgla LA, Keskula DR. Reliability of lower extremity functional performance tests. J Orthop
408 Sports Phys Ther. 1997;26:138-142.
409 11. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical
410 experience and quality of health care. Ann Intern Med. 2005;142:260-273.
411 12. Cohen SB, Sekiya JK. Allograft safety in anterior cruciate ligament reconstruction. Clin Sports
412 Med. 2007;26:597-605.
413 13. Cook C. Emotional-based practice. J Man Manip Ther. 2011;19:63-65.
414 14. Czuppon S, Racette BA, Klein SE, Harris-Hayes M. Variables associated with return to sport
415 following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med.
416 2014;48:356-364.
417 15. Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate
418 Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47:1487-
419 1500.
420 16. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of
421 Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6:e34.
422 17. Falconiero RP, DiStefano VJ, Cook TM. Revascularization and ligamentization of autogenous
423 anterior cruciate ligament grafts in humans. Arthroscopy. 1998;14:197-205.
424 18. Garrison JC, Bothwell JM, Wolf G, Aryal S, Thigpen CA. Y Balance Test Anterior Reach Symmetry
425 at Three Months Is Related to Single Leg Functional Performance at Time of Return to Sports
426 Following Anterior Cruciate Ligament Reconstruction. Int J Sports Phys Ther. 2015;10:602-611.
19
427 19. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can
428 reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J
429 Sports Med. 2016;50:804-808.
430 20. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture
431 (REDCap)--a metadata-driven methodology and workflow process for providing translational
432 research informatics support. J Biomed Inform. 2009;42:377-381.
433 21. Hewett TE, Di Stasi SL, Myer GD. Current concepts for injury prevention in athletes after anterior
434 cruciate ligament reconstruction. Am J Sports Med. 2013;41:216-224.
435 22. Hewett TE, Ford KR, Hoogenboom BJ, Myer GD. Understanding and preventing acl injuries:
436 current biomechanical and epidemiologic considerations-update 2010. North American journal
437 of sports physical therapy: NAJSPT. 2010;5:234.
438 23. Hui C, Salmon LJ, Kok A, Maeno S, Linklater J, Pinczewski LA. Fifteen-year outcome of endoscopic
439 anterior cruciate ligament reconstruction with patellar tendon autograft for "isolated" anterior
440 cruciate ligament tear. Am J Sports Med. 2011;39:89-98.
441 24. Joreitz R, Lynch A, Rabuck S, Lynch B, Davin S, Irrgang J. Patient-Specific and Surgery-Specific
442 Factors That Affect Return to Sport after Acl Reconstruction. Int J Sports Phys Ther. 2016;11:264-
443 278.
444 25. Kaplan Y. Identifying individuals with an anterior cruciate ligament-deficient knee as copers and
445 noncopers: a narrative literature review. J Orthop Sports Phys Ther. 2011;41:758-766.
446 26. Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for
447 sports participation. Sports Med. 2004;34:269-280.

448 27. Kyritsis P, Bahr R, Landreau P, Miladi R, Witvrouw E. Likelihood of ACL graft rupture: not meeting
449 six clinical discharge criteria before return to sport is associated with a four times greater risk of
450 rupture. Br J Sports Med. 2016;50:946-951.
451 28. Lentz TA, Zeppieri G, Jr., George SZ, et al. Comparison of physical impairment, functional, and
452 psychosocial measures based on fear of reinjury/lack of confidence and return-to-sport status
453 after ACL reconstruction. Am J Sports Med. 2015;43:345-353.
454 29. Logerstedt D, Grindem H, Lynch A, et al. Single-legged hop tests as predictors of self-reported
455 knee function after anterior cruciate ligament reconstruction: the Delaware-Oslo ACL cohort
456 study. Am J Sports Med. 2012;40:2348-2356.

457 30. Logerstedt DS, Scalzitti D, Risberg MA, et al. Knee Stability and Movement Coordination
458 Impairments: Knee Ligament Sprain Revision 2017. J Orthop Sports Phys Ther. 2017;47:A1-A47.
459 31. Logerstedt DS, Snyder-Mackler L, Ritter RC, Axe MJ, Godges JJ, Orthopaedic Section of the
460 American Physical Therapist A. Knee stability and movement coordination impairments: knee
461 ligament sprain. J Orthop Sports Phys Ther. 2010;40:A1-A37.
462 32. Makhni EC, Crump EK, Steinhaus ME, et al. Quality and Variability of Online Available Physical
463 Therapy Protocols From Academic Orthopaedic Surgery Programs for Anterior Cruciate Ligament
464 Reconstruction. Arthroscopy. 2016;32:1612-1621.
465 33. Marx RG, Jones EC, Angel M, Wickiewicz TL, Warren RF. Beliefs and attitudes of members of the
466 American Academy of Orthopaedic Surgeons regarding the treatment of anterior cruciate
467 ligament injury. Arthroscopy. 2003;19:762-770.
468 34. McRae SM, Chahal J, Leiter JR, Marx RG, Macdonald PB. Survey study of members of the
469 Canadian Orthopaedic Association on the natural history and treatment of anterior cruciate
470 ligament injury. Clin J Sport Med. 2011;21:249-258.
471 35. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time
472 lags in translational research. Journal of the Royal Society of Medicine. 2011;104:510-520.
473 36. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop
474 tests after anterior cruciate ligament rupture. Am J Sports Med. 1991;19:513-518.
20
475 37. Pryor RR, Casa DJ, Vandermark LW, et al. Athletic training services in public secondary schools: a
476 benchmark study. J Athl Train. 2015;50:156-162.
477 38. Sugimoto D, Myer GD, McKeon JM, Hewett TE. Evaluation of the effectiveness of neuromuscular
478 training to reduce anterior cruciate ligament injury in female athletes: a critical review of
479 relative risk reduction and numbers-needed-to-treat analyses. Br J Sports Med. 2012;46:979-
480 988.
481 39. Thomee R, Kaplan Y, Kvist J, et al. Muscle strength and hop performance criteria prior to return
482 to sports after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1798-1805.
483 40. Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, Schmitt LC. Young Athletes Cleared
484 for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually
485 Meet Recommended Return-to-Sport Criterion Cutoffs? J Orthop Sports Phys Ther. 2017;47:825-
486 833.
487 41. Undheim MB, Cosgrave C, King E, et al. Isokinetic muscle strength and readiness to return to
488 sport following anterior cruciate ligament reconstruction: is there an association? A systematic
489 review and a protocol recommendation. Br J Sports Med. 2015;49:1305-1310.
490 42. van Grinsven S, van Cingel RE, Holla CJ, van Loon CJ. Evidence-based rehabilitation following
491 anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2010;18:1128-
492 1144.
493 43. van Melick N, van Cingel RE, Brooijmans F, et al. Evidence-based clinical practice update:
494 practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review
495 and multidisciplinary consensus. Br J Sports Med. 2016;50:1506-1515.

496 44. Wilk KE, Arrigo CA. Rehabilitation Principles of the Anterior Cruciate Ligament Reconstructed
497 Knee: Twelve Steps for Successful Progression and Return to Play. Clin Sports Med. 2017;36:189-
498 232.
499
21
Knee strength 91.6
80
Functional/balance 86.9
testing 82.5
Knee ROM 80.3

61.9
Knee effusion 70.6

59.6
PROMs 42.7
45.3
ACL laxity test 28.9

28.5
None 0.3
1.2
0 10 20 30 40 50 60 70 80 90 100
% of responses
n=1074 Jogging Modified Sports Activity

FIGURE 1: Criterion based responses for initiating jogging and modified sports activities
following ACLR. Abbreviations: ROM, Range of Motion; PROMs, Patient Reported Outcome
Measures
80.6
MMT
74.3
17.3
Isometric or HHD
16.8
17.3
Isokinetics
19.6
27.6
RM testing
28.5
0 10 20 30 40 50 60 70 80 90
% of responses
Jogging (n=984) Modified Sports Activities (n=859)

FIGURE 2: Mode of strength testing from those that responded that they utilize strength testing
in decision making to initiate running and modified sports activity. Abbreviations: MMT, manual
muscle testing; HHD, hand-held dynamometry; RM, repetition maximum
45
A 39.8
39.1 38.5
40
35.2
35
30
% of responses
25 22.1 22.4
20.7 20.4 20.3
20 17.4
16.1
14 14.7
15 13.4
10.8 10.1 10.1

10 7.6 8.3
7 6
5 2.9
1.6 1.4
0
>70% >75% >80% >85% >90% Other Value
Quadriceps LSI criteria for jogging
RM leg Press (n=186) RM Knee extension (n=69) Isokinetics (n=145) Isometric or HHD (n=143)
60
B
50.3 50
50
39.8 38.9
40
% of responses
30
25
21.6 20.4
20 17.6 18.3
16.7
13.4 14
11.1 11.3
9.5
10
5 4.2 3.7 4.2
2.8 1.6 2 2.4
0
0
>75% >80% >85% >90% >95% Other Value
Quadriceps LSI criteria for modified sports activity

RM leg Press (n=199) RM Knee extension (n=72) Isokinetics (n=164) Isometric or HHD (n=142)
FIGURE 3: Requirements of quadriceps limb symmetry indices for various modes of strength
testing to initiate (A) jogging and (B) modified sports activity. Abbreviations: HHD, hand-held
dynamometry; RM, repetition maximum
A
Vail sports cord test x2=4.048, P=0.044
LESS x2=3.98, P=0.046

Balance assessment tool x2=0.151, P=0.697
x2=14.576, P<0.001*
Drop vertical jump
Single limb hop tests x2=1.344, P=0.246
YBT/SEBT x2=10.895, P=0.001*

FMS x2=1.414, P=0.234
0 10 20 30 40 50 60 70 80 90 100
% of responses
Whole sample (n=1074) High Volume Practitioner (n=407) Low Volume Practitioner (n=347)
B
LESS x2=0.216, P=0.642
Drop vertical jump x2=1.675, P=0.196
YBT/SEBT x2=17.46, P<0.001*

FMS x2=4.748, P=0.029
0 10 20 30 40 50 60 70 80 90 100
% of responses
Whole sample (n=1074) >16 years experience (n=451) 0-4 years experience (n=246)
C
LESS x2=0, P=0.989

Drop vertical jump x2=2.041, P=0.153
YBT/SEBT x2=1.632, P=0.201

FMS x2= 2.131, P= 0.144
0 10 20 30 40 50 60 70 80 90 100
% of responses
Whole sample (n=1074) No OCS/SCS certification (n=508) OCS/SCS certification (n=564)

FIGURE 4: Associations of functional test selection and clinician characteristics indicative of
advanced clinical proficiency including (A) volume of ACL’s seen/year, (B) years of clinical
experience, and (C) specialty certification to determine readiness for modified sports activity.
* Denotes significance at P ≤ 0.00625 after Bonferroni correction
LEFS 39.2
KOS 14.2
IKDC 11.3
Fear or Athletic Confidence 9.7
Other scale 7.2
SF-36 1.6
PROMIS 1.2
Pedi-FABS 0.4
0 5 10 15 20 25 30 35 40 45
n=487 % of responses
FIGURE 5: Frequencies of type of patient reported outcome measures (PROMs) utilized from
those that reported their utilization in decision making to initiate modified sports activity.
Abbreviations: LEFS, Lower Extremity Functional Scale; KOS, Knee Outcome Survey; IKDC,
International Knee Documentation Committee; SF-36, Short Form Survey; PROMIS, Patient
Reported Outcome Measure Information System; Pedi-FABS, Pediatric Functional Activity Brief
Scale.
TABLE 1 Demographics of the Study Respondents
Demographics Frequency, n (%)
Years of practice as a physical therapist

0-4 years 246 (22.9)
5-10 years 218 (20.3)
11-15 years 157 (14.6)
≥ 16 years 451 (42.0)
Primary practice setting*

Private practice 460 (42.8)

Hospital based outpatient 384 (35.8)
Corporate owned outpatient practice 118 (11.0)
Academic/Collegiate facility 73 (6.8)
Other 37 (3.4)
Region of Practice**
South Atlantic (DE, FL, GA, MD, NC, SC, VA, WV) 200 (18.6)
Middle Atlantic (NJ, NY, PA) 157 (14.6)

East North Central (IL, IN, MI, OH, WI) 162 (15.1)
West North Central (IA, KS, MN, MO, NE, ND, SD) 107 (9.1)
East South Central (AL, KY, MS, TN) 37 (3.5)
West South Central (AR, LA, OK, TX) 85 (7.9)
New England (CT, ME, MA, NH, RI, VT) 144 (5.9)
Pacific (AK, CA, HI, OR, WA) 149 (13.8)
Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 95 (8.9)
Number of ACL’s treated/year

0 11 (1.0)
1-5 (low volume) 347 (32.3)
6-10 (medium volume) 309 (28.8)
>10 (high volume) 407 (37.9)
ABPTS certification in Orthopedics (OCS) or Sports (SCS) ***

Yes 564 (52.5)
No 508 (47.3)
Current APTA Member****

Yes 993 (92.5)
No 69 (6.4)
*2 (0.2%) of respondents did not identify primary practice setting

**28 (2.6%) of respondents did not identify state of practice
***2 (0.2%) of respondents did not identify if they were ABPTS Certified in Orthopedics or Sports
****12 (1.1%) of respondents did not identify if they were a current APTA member
TABLE 2 ASSOCIATIONS WITH LENGTH OF TREATMENT COURSE AND PHYSICAL THERAPIST CHARACTERISTICS
N of those with <6 N of those with >6 X2 Value P value Effect Size
months course of months course of
treatment treatment
Years of 0-4 years 102 143 34.253 < 0.001* 0.222
experience
>16 years 291 159
ACLs 1-4 ACL/year 212 134 15.200 < 0.001* 0.142
treated/year
>10 ACL/year 190 214
OCS/SCS Yes 309 198 8.909 0.003* 0.091
certification
No 291 270
*Denotes significance at P<0.05
Abbreviations: OCS: Orthopedic Certified Specialist; SCS: Sports Certified Specialist

TABLE 3 Time-based responses to initiate functional milestones following ACLR
Jogging Modified Sports Activity Unrestricted Return to Sport
months n, (%) months n, (%) months n, (%)
2-3 200 (18.6) <3 66 (6.2) 4-5 22 (2.1)
3-4 622 (58.0) 4-5 538 (50.6) 6-7 251 (23.4)
4-5 204 (19.0) 6-7 337 (31.6) 7-8 157 (14.7)
>6 38 (3.5) 8-9 46 (4.3) 9-12 426 (39.8)
9-12 27 (2.5) > 12 57 (5.3)
> 12 3 (0.3)
Typically do not treat patients at this functional milestone
9 (0.8) 47 (4.4) 158 (14.8)

TABLE 4 Functional test selection utilized to initiate jogging and modified sports activity
Jogging Modified Sports Activity
(n=933) (n=886)
n, (%) n, (%)
Lateral Step Down test 653 (70) --
YBT/SEBT 519 (55.6) 432 (48.8)
FMS 293 (31.4) 276 (31.2)
SLR 262 (28.1) --
Balance Assessment Tool 130 (13.9) 107 (12.1)

Single Limb Hop test -- 790 (89.2)
DVJ -- 350 (39.5)
LESS -- 94 (10.6)
Vail Sports Cord test -- 66 (7.4)
Other test not listed 233 (25) 112 (12.6)
Abbreviations: YBT, Y Balance Test; SEBT, Star Excursion Balance Test; FMS, Functional
Movement Screen; SLR, Straight Leg Raise; DVJ, Drop Vertical Jump; LESS, Landing Error Scoring
System
TABLE 5 Hop test selection for decision making to
return to modified sports activity
Utilized Hop Test Battery* (n=790) n, (%)
One hop test only 154, (19.5)
At least two types of hop tests 627, (79.4)
At least three types of hop tests 426, (53.9)
Four types of hop tests 214, (27.1)

*Hop tests included: single hop for distance, triple hop for
distance, triple crossover hop for distance, timed 6-m hop
ACLR PT/Ortho Survey
Dear Colleagues,
Anterior Cruciate Ligament (ACL) reconstruction is a common surgical procedure and patients often require an
intensive and progressive course of rehabilitation. Although there has been extensive research on ACL reconstruction,
clinical practice patterns detailing rehabilitation are currently unclear. In an attempt to gain insight into this factor,
The Sports Medicine and Performance Center at The Children's Hospital of Philadelphia invites you to participate in this
survey.
In order to participate you need to be a physical therapist or orthopaedic surgeon who currently works with patients
following ACL reconstruction. The survey takes approximately 5-7 minutes to complete. Your participation is
completely voluntary and your responses are anonymous. The survey includes a few demographics questions followed
by a series of questions regarding your rehabilitation practices in the management of athletes after ACL
reconstruction surgery.
Your responses will be kept completely confidential and analyzed anonymously. Please feel free to contact Dr. Elliot
Greenberg (greenberge@email.chop.edu) or Dr. Theodore Ganley (ganley@email.chop.edu) with any questions,
concerns or technical problems. If you have questions about your rights as a research subject, you can contact the
Orthopedics research office at Children’s Hospital of Philadelphia (267) 426-7607.
If you are interested in participating in this study, please select this option in the consent question below.
Thank you in advance for your participation.
Dr. Elliot M. Greenberg, PT, PhD, OCS

Dr. Theodore J. Ganley, MD
1. Consent I consent to participate in the study

I do not consent to participate in the study
2. Are you an orthopaedic surgeon or a physical Orthopaedic surgeon

therapist? Physical therapist
Neither
03/05/2018 6:21pm www.projectredcap.org

PRACTICE PATTERNS
3. How many anterior cruciate ligament (ACL) None

reconstructions do you treat per year? 1-5
6-10
10+
4. What is your primary practice setting? Private practice

Hospital-based outpatient facility
Corporate-owned outpatient practice
Academic/collegiate rehabilitation facility
Other
4a. Other:
(Please specify)
5. How many years have you been practicing? 0-4 years

5-10 years
11-15 years
16 or more
6. Are you currently an APTA member? Yes

No
7. Are you an APTA Orthopedic (OCS) or Sports (SCS) Yes

Certified Specialist? No

6. What state do you practice in?
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
7. Where did you hear about this survey? Orthopedic section email
Sports section email
Other email
Social media (Facebook, Twitter, etc.)

For the remainder of this survey, please answer the questions based upon your typical
treatment of the patient described below.
"Your patient is a 17-year-old female soccer player who underwent ACL reconstruction using a
hamstring autograft. There were no concomitant injuries and she is having an uncomplicated
post-operative recovery. Her goal is to return to soccer competition at the collegiate level upon
full recovery."
8. For the patient described above, how long would your 1-3 months
typical course of rehabilitation be? (i.e. how long 4-5 months
would you treat them within an office setting?) 6-8 months
9-12 months
>12 months
9. Who is responsible for determining this athlete's Orthopaedic surgeon

readiness to begin to run, initiate plyometric and Rehabilitation specialist (PT, ATC)
agility training and unrestricted return to sports? Both the orthopeadic and rehabilitation specialist
Other
9a. Other:
PROGRESSION TO JOGGING AFTER ACL RECONSTRUCTION

10. I would typically allow the athlete in this example 2-3 months
to begin jogging at months post-surgery. 3-4 months
(fill in the blank from the choices available) 4-5 months
6+ months
11. Are there specific physical tests, examination Knee range of motion
findings, or criteria that you utilize in order to Strength assessment (manual muscle testing)
assist in the decision to progress to jogging? Strength assessment (handheld dynamometry)
(Check all that apply) Strength assessment (isokinetic testing)
Knee effusion
Lower extremity functional testing or balance

assessment
Patient-reported outcome measures
ACL laxity test (e.g. Lachmans, Anterior Drawer,
etc.)
None
Other
(Check all that apply)
11a. Other:
If “Knee strength” is selected:

12. Strength Assessment: What tests do you use? Manual Muscle Testing (MMT)
(Check all that apply) Isometric Testing (i.e. Hand Held Dynamometry
(HHD))
Isokinetic testing
Repetition maximum (RM) testing
Other
12a. Other:

If “Isometric testing or isokinetic testing” is selected:
13. What QUADRICEPS strength criteria is required for Side-to-side deficit of less than 30%
progression to jogging? Side-to-side deficit of less than 25%
Side-to-side deficit of less than 20%
Other
13a. Other:
14. What HAMSTRINGS strength criteria is required for Side-to-side deficit of less than 30%
Other
14a. Other:
If “Isokinetic testing” is selected:

15. What speed(s) of testing do you utilize for 60 degrees per second
isokinetic testing? (Check all that apply) 120 degrees per second
180 degrees per second
Other
15a. Other:
If “Repetition maximum testing” is selected:

16. Repetition maximum (RM) Testing: What means of Leg Press
RM testing do you utilize? Knee Extension
(Check all that apply) Knee Flexion
Other
16a. Other:
If “Leg press” is selected:

17. Leg Press: What criteria is required for progression Side-to-side deficit of less than 30%
to jogging? Side-to-side deficit of less than 25%
Other
17a. Other:
If “Knee extension” is selected:

18. Knee Extension: What criteria is required for Side-to-side deficit of less than 30%
Other
18a. Other:

If “Knee flexion” is selected:
19. Knee Flexion: What criteria is required for Side-to-side deficit of less than 30%
Other
19a. Other: _______________________________
If “Lower extremity functional testing…” is selected:

20. Functional performance: What tests do you use to Straight leg raise
assist with the decision to progress to jogging? Functional movement screen (FMS)
(Check all that apply) Y or Star balance testing
Lateral step down test
Balance assessment tool (e.g. Balance Error
Scoring System BESS)
Other
20a. Other:
If “Functional movement screen” is selected:

21. What is your criteria for advancement on functional Composite FMS score
movement screen? (Check all that apply) Performance on isolated movements
Side-side symmetry for unilateral movements
Other
21a. Other:
If “Y-balance test” is selected:

22. What is your criteria for advancement on Y-Balance Anterior reach difference of less than 4cm
Test? (Check all that apply) Composite reach with less than 10% side-to-side
asymmetry
Other
22a. Other:
If “Patient-reported outcome measures” is selected:

23. Patient-Reported Outcome Measures(PROM): What Lower Extremity Functional Scale (LEFS)
PROM do you use to assist with the decision to progress International Knee Disability Committee (IKDC)
to jogging? (Check all that apply) Knee Outcome Survey (KOS)
Short-Form 36 (SF-36)
PROMIS Quality of Life Measures
Pedi-Fabs Scale
Fear or Self-Efficacy Based Survey (e.g. Tampa
Scale of Kinesiophobia)
Other
23a. Other:

PROGRESSION TO MODIFIED SPORTS ACTIVITY AFTER ACL RECONSTRUCTION
24.I would typically allow the athlete in this example ≤ 3 months

to begin modified sports-specific activities 4-5 months
(agilities, sports-specific drills/skills, etc) at 6-7 months
months post-surgery. (fill in the blank 8-9 months
from the choices available) 9-12 months
12 or more months
I typically do not see patient's during this phase
of rehabilitation
25. Are there specific physical tests, examination Knee range of motion
findings, or criteria that you utilize in order to Knee strength
assist in the decision to progress to Knee effusion
sports-specific training? (Check all that apply) Lower extremity functional testing or balance
assessment
Patient-reported outcome measures
ACL laxity test (e.g. Lachmans, Anterior Drawer,
etc.)
None
Other
25a. Other:
If “Knee strength” is selected:

26. Strength Assessment: What tests do you use? Manual Muscle Testing (MMT)
(Check all that apply) Isometric Testing (i.e. Hand Held Dynamometry
(HHD))
Isokinetic testing
Repetition maximum (RM) testing
Other
26a. Other:

If “Isometric testing or isokinetic testing” is selected:
27. What QUADRICEPS strength criteria is required for Side-to-side deficit of less than 25%
progression to sport-specific activities? Side-to-side deficit of less than 20%
Other
27a. Other:
28. What HAMSTRINGS strength criteria is required for Side-to-side deficit of less than 25%
Other
28a. Other:
If “Isokinetic testing” is selected:

29. What speed(s) of testing do you utilize for 60 degrees per second
isokinetic testing? (Check all that apply) 120 degrees per second
Other
29a. Other:
If “Repetition maximum testing” is selected:

30. Repetition maximum (RM) Testing: What means of Leg Press
RM testing do you utilize? Knee Extension
(Check all that apply) Knee Flexion
Other
30a. Other:
If “Leg press” is selected:

31. Leg Press: What criteria is required for progression Side-to-side deficit of less than 25% to
sport-specific activities? Side-to-side deficit of less than 20%
Other
31a. Other:
If “Knee extension” is selected:

32. Knee Extension: What criteria is required for Side-to-side deficit of less than 25%
Other
32a. Other:

If “Knee flexion” is selected:
33. Knee Flexion: What criteria is required for Side-to-side deficit of less than 25%
Other
33a. Other: _______________________________
If “Lower extremity functional testing…” is selected:

34. Functional Performance: what tests do you use to Functional movement screen (FMS)
assist with the decision to progress to Y balance test sport-
specific activities? (Check all that apply) Single leg hop test
Drop vertical jump
Balance assessment tool (e.g. Balance Error
Scoring System BESS)
Patient-reported outcome measure Landing
Error Scoring System (LESS) test Vail sport
test
Other
34a. Other:
If “Functional movement screen” is selected:

35. What is your criteria for advancement on functional Composite FMS score
movement screen? (Check all that apply) Performance on isolated movements
Side-side symmetry for unilateral movements
Other
35a. Other:
If “Y-balance test” is selected:

36. What is your criteria for advancement on Y-Balance Anterior reach difference of less than 4cm
Test? (Check all that apply) Composite reach with less than 10% side-to-side
asymmetry
Other
36a. Other:
If “Single leg hop test” is selected:

37. What hops do you use on hop testing? Single hop
(Check all that apply) Triple hop
Cross-over triple hop
6M timed hop
Other
37a. Other:
38. What is your criteria for advancement on single leg Side-to-side deficit of less than 25%
hop testing? Side-to-side deficit of less than 20%
Other
38a. Other:

If “Patient-reported outcome measures” is selected:
39. Patient-Reported Outcome Measures(PROM): What Lower Extremity Functional Scale (LEFS)
PROM do you use to assist with the decision to progress International Knee Disability Committee (IKDC)
to sport-specific activities? (Check all that apply) Knee Outcome Survey (KOS)
Short-Form 36 (SF-36)
PROMIS Quality of Life Measures
Pedi-Fabs Scale
Fear or Self-Efficacy Based Survey (e.g. Tampa
Scale of Kinesiophobia)
Other
39a. Other:
PROGRESSION TO FULL UNRESTRICTED SPORTS ACTIVITY
40. I would typically allow the athlete in this example ≤ 3 months

to begin unrestricted sports at months 4-5 months
post-surgery. (fill in the blank from the choices 6-7 months

available) 7-8 months
9-12 months
12 or more months
I typically do not see patients during this phase
of rehabilitation
41. Are there any additional tests, measures, or Yes

criteria, beyond those needed to initiate No
sports-related activities, that you require before

allowing an athlete to participate in UNRESTRICTED
sports activity?
41a. What additional tests or measures do you require?
RECOMMENDATION OF ONGOING INJURY PREVENTION PROGRAM
42. Would you recommend an ACL injury prevention program Yes for
this patient at discharge? No
If ACL prevention program recommended:

43. What ACL prevention program do you recommend? Sportsmetrics
Prevent Injury, Enhance Performance (PEP) Program
FIFA 11+
Other
43a. Other:
USE OF FUNCTIONAL BRACING AT TIME OF RETURN TO SPORTS
44. Would you typically recommend the use of a knee brace Yes
during sports activities for this patient? No
If brace recommended:
45. What type of brace do you typically recommend? Functional ACL brace
Neoprene knee sleeve
Other
45a. Other:

Reabilitação LCA 2

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Reabilitação LCA 2

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Rehabilitation Practice Patterns following Anterior Cruciate

Ligament Reconstruction: A Survey of Physical Therapists

† Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia,

¥ New York Institute of Technology, Department of Physical Therapy, Old Westbury, NY

*Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA

*Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA

Conflict of Interest Statement:

There was no grant support for this study

Address all correspondence to:

3 Background: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an

4 intensive course of post-operative rehabilitation. Although guidelines outlining evidence-based

6 therapists are unknown.

8 Objectives: To analyze the current landscape of clinical practice as it pertains to rehabilitation

24 small proportion of those concerned fear or athletic confidence scales (10%).

26 Conclusions: Considerable variation exists amongst APTA members with regards to

27 rehabilitation following ACLR. This variability in practice may contribute to suboptimal

28 outcomes and confusion among practitioners and patients.

41 care costs and increased disability.

45 graft maturation and physiological healing.17 However, rehabilitation recommendations have

51 literature.6 Additionally, literature analysis reveals significant variation in published

52 rehabilitation protocols and inconsistent recommendations of specific performance measures or

54 rehabilitation.32, 43 This discordance contributes to a complicated practice environment, which

60 current literature, in order to determine if clinical practice is reflective of up-to-date

61 recommendations and scientific evidence. Additionally, the relationship of clinical practice

62 patterns to clinician characteristics will be analyzed in order to understand some of the

63 underlying factors that may be related to individual clinical decision making.

66 A team of clinicians (3 physical therapists and 1 orthopaedic surgeon) highly experienced in

69 initial phase of development consisted of identification of key rehabilitation transitional phases

74 case vignette representative of a typical patient encountered within a sports or orthopaedic

79 soccer competition at the collegiate level upon full recovery."

85 consisted of 6 sections: 1) Clinician demographics and clinical practice information, 2) Clinical

87 agilities, sports-specific drills/skills), 4) Return to unrestricted sports 5) Use of injury prevention

88 programs and 6) Use of functional bracing upon return to sports.

94 The complete survey instrument is available to view online. (eAppendix)

110 ensure the quality of reporting the findings of this study.16

111 Data Analysis

124 Bonferroni correction was utilized to determine statistical significance.

127 Survey Response

133 newsletter or word of mouth.

134 Respondents’ Profile

140 were board certified in Orthopaedics or Sports Physical Therapy (52.5%).

141 Decision-making regarding activity progression

144 surgeon and the physical therapist.

145 Time Criterion

147 long would you treat them within an office setting?)”

152 or SCS certification indicated a longer overall duration of clinical care.

154 unrestricted return to sports], at ______ months post-surgery?”

162 other transition points.

164 Criterion Based Measures

174 progression. (FIGURE 1)

176 Knee Strength

186 remaining 43.9% (n=280/638) used it in adjunct to more objective modes.

199 Functional Testing

208 of the sample reporting an LSI of 75% to 85% being acceptable.

215 side-to-side movement symmetry during the unilateral movements.

218 YBT/SEBT (X2=17.46, P<0.001). (FIGURE 4)

221 Patient Reported Outcome Measures

226 characteristics and the use of PROMs.

228 Post-Rehabilitation Factors: Injury Prevention Programs and Functional Bracing

243 consensus of an ideal postoperative rehabilitation program.15, 43

267 established a network of community-based alternative practitioners (e.g. athletic trainers,

270 behind time-based decisions amongst these groups of practitioners.

288 may not be justified from a business perspective.