Alshewaier, Yeowell & Fatoye (2016) The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: a systematic review

Objective To evaluate the effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury.
Methods The following databases were searched: PubMed, Ovid, The Cochrane Library and Web of Science. Studies published between the inception of the databases and December 2015 were sought using appropriate keywords in various combinations. This search was supplemented with a manual search of the references of selected studies. Studies were assessed for methodological quality using the Physiotherapy Evidence Database scale.
Results A total of 500 studies were identified, of which eight studies met the inclusion criteria and were included in the present review. The average Physiotherapy Evidence Database score for the studies included was 5.8, which reflects an overall moderate methodological quality. The eight studies investigated a total of 451 subjects of which 71% (n=319) were males. The age of the participants in the eight studies ranged from 15 to 57 years. The duration of the intervention in the studies ranged from 3 to 24 weeks. This review found that pre-operative physiotherapy rehabilitation is effective for improving the outcomes of treatment following anterior cruciate ligament injury, including increasing knee-related function and improving muscle strength. However, whilst there was a significant improvement in quality of life from baseline following intervention, no significant difference in quality of life was found between the control and intervention groups.
Conclusions There is evidence to suggest that pre-operative physiotherapy rehabilitation is beneficial to patients with anterior cruciate ligament injury.

Grindem, Snyder-Mackler, Moksnes, Engebretsen & Risberg (2016)  Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study

Background Knee reinjury after ACL reconstruction is common and increases the risk of osteoarthritis. There is sparse evidence to guide return to sport (RTS) decisions in this population.
Objectives To assess the relationship between knee reinjury after ACL reconstruction and (1) return to level I sports, (2) timing of RTS and (3) knee function prior to return.
Methods 106 patients who participated in pivoting sports participated in this prospective 2-year cohort study. Sports participation and knee reinjury were recorded monthly. Knee function was assessed with the Knee Outcome Survey—Activities of Daily Living Scale, global rating scale of function, and quadriceps strength and hop test symmetry. Pass RTS criteria were defined as scores >90 on all tests, failure as failing any.
Results Patients who returned to level I sports had a 4.32 (p=0.048) times higher reinjury rate than those who did not. The reinjury rate was significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed. 38.2% of those who failed RTS criteria suffered reinjuries versus 5.6% of those who passed (HR 0.16, p=0.075). More symmetrical quadriceps strength prior to return significantly reduced the knee reinjury rate.
Conclusions Returning to level I sports after ACL reconstruction leads to a more than 4-fold increase in reinjury rates over 2 years. RTS 9 months or later after surgery and more symmetrical quadriceps strength prior to return substantially reduce the reinjury rate.

Kyritsis, Bahr, Landreau, Miladi &Witvrouw (2016) Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture

Background The decision as to whether or not an athlete is ready to return to sport (RTS) after ACL reconstruction is difficult as the commonly used RTS criteria have not been validated.
Purpose To evaluate whether a set of objective discharge criteria, including muscle strength and functional tests, are associated with risk of ACL graft rupture after RTS.
Materials and methods 158 male professional athletes who underwent an ACL reconstruction and returned to their previous professional level of sport were included. Before players returned to sport they underwent a battery of discharge tests (isokinetic strength testing at 60°, 180° and 300°/s, a running t test, single hop, triple hop and triple crossover hop tests). Athletes were monitored for ACL re-ruptures once they returned to sport (median follow-up 646 days, range 1–2060).
Results Of the 158 athletes, 26 (16.5%) sustained an ACL graft rupture an average of 105 days after RTS. Two factors were associated with increased risk of ACL graft rupture: (1) not meeting all six of the discharge criteria before returning to team training (HR 4.1, 95% CI 1.9 to 9.2, p≤0.001); and (2) decreased hamstring to quadriceps ratio of the involved leg at 60°/s (HR 10.6 per 10% difference, 95% CI 10.2 to 11, p=0.005).
Conclusions Athletes who did not meet the discharge criteria before returning to professional sport had a four times greater risk of sustaining an ACL graft rupture compared with those who met all six RTS criteria. In addition, hamstring to quadriceps strength ratio deficits were associated with an increased risk of an ACL graft rupture. 

Tristan Chai