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_Combining return to sport, psychological readiness, body mass, hamstring strength symmetry, and hamstring/quadriceps ratio increases the risk of a second anterior cruciate ligament injury

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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To investigate the combinations of variables that comprise the biopsychosocial model domains to identify clinical profiles of risk and protection of second anterior cruciate ligament injury.

Methods

One hundred and forty-five patients for return-to-sport testing after anterior cruciate ligament (ACL) reconstruction (ACLR) were contacted, and 97 were deemed eligible. All were evaluated between 6 and 24 months and followed up for 2 years. Participants answered the International Knee Documentation Committee (IKDC) and Anterior Cruciate Ligament–Return to Sport after Injury Scale (ACL-RSI), performed the postural stability assessment using the Biodex Balance System, and assessed muscle strength at 60° and 300°/s on the isokinetic dynamometer. Personal factors (age, gender, body mass index), body structures (graft type and concomitant injuries), and environmental factors (time between surgery and evaluation) were also collected. The participants were asked about the occurrence of a second ACL injury and return to sport after 2 years of follow-up. Classification and regression tree (CART) analysis was used to determine predictors of a second ACL injury. The receiver operating characteristic (ROC) curve was performed to verify the accuracy of the CART analysis, in addition to the sensitivity, specificity, and relative risk (RR) of the model.

Results

Of the initial 97 participants, 88 (89.8%) responded to follow-up and 14 (15.9%) had a second ACL injury (11 graft ruptures and three contralateral ACL). CART analysis identified the following variables as predictors of second ACL injury: return to sport, hamstring strength symmetry at 300°/s, ACL-RSI score, hamstrings/quadriceps ratio at 60°/s, and body mass index (BMI). CART correctly identified 9 (64.3%) of the 14 participants who were reinjured and 71 (95.9%) of the 74 participants who were not. The total correct classification was 90.9%. The area under the ROC curve was 0.88 (95% CI 0.72–0.99; p < 0.001), and the model showed a sensitivity of 75% (95% CI 42.8–94.5), specificity of 93.4% (95% CI 85.3–97.8), and RR of 15.9 (95% CI 4.9–51.4; p < 0.0001).

Conclusion

The combination of hamstring strength symmetry, hamstring/quadriceps ratio (body functions); return to sport (activity and participation); psychological readiness; and BMI (personal factors) could identify three clinical risk profiles for a second ACL injury with good accuracy.

Level of Evidence

IV.

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Data availability

Raw data can be made available upon reasonable request.

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Acknowledgements

We would like to thank the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brazil (CAPES) for supporting this research.

Funding

This research was partially financed by the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (FUNCAP) through the aid for exceptional expenses of small value (Edital n° 03/2019), and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, grant number Finance Code 001.

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Authors and Affiliations

  1. Knee and Sports Research Group, Federal University of Ceará, Alexandre Baraúna Street, 949 – 1° andar – Rodolfo Teófilo, Fortaleza, CE, 60430-160, Brazil

    Gabriel Peixoto Leão Almeida, Thamyla Rocha Albano, Carlos Augusto Silva Rodrigues, Maria Larissa Azevedo Tavares & Pedro Olavo de Paula Lima

  2. Master Program in Physiotherapy and Functioning, Federal University of Ceará, Fortaleza, CE, Brazil

    Gabriel Peixoto Leão Almeida, Thamyla Rocha Albano, Carlos Augusto Silva Rodrigues, Maria Larissa Azevedo Tavares & Pedro Olavo de Paula Lima

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  1. Gabriel Peixoto Leão Almeida
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  2. Thamyla Rocha Albano
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  4. Maria Larissa Azevedo Tavares
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Contributions

All authors contributed to the conception and design of the study. The material preparation, data collection and analysis were performed by TRA, MLAT, CASR and GPLA. The first draft of the manuscript was written by TRA and GPLA. Supervision and written review of the study were carried out by GPLA and POPL. All authors commented on the previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Gabriel Peixoto Leão Almeida.

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All authors declare that there are no conflicts of interested involved in writing this article.

Ethical approval

This study was approved by the Ethics Committee at the Federal University of Ceará with protocol number 1.000.404.

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Patients provided informed consent to take part in the study.

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Almeida, G.P.L., Albano, T.R., Rodrigues, C.A.S. et al. _Combining return to sport, psychological readiness, body mass, hamstring strength symmetry, and hamstring/quadriceps ratio increases the risk of a second anterior cruciate ligament injury. Knee Surg Sports Traumatol Arthrosc 31, 5087–5095 (2023). https://doi.org/10.1007/s00167-023-07559-w

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