Athletes who wish to resume high-level activities after an injury to the anterior cruciate ligament (ACL) are often advised to undergo surgical reconstruction. Nevertheless, ACL reconstruction (ACLR) does not equate to normal function of the knee or reduced risk of subsequent injuries. In fact, recent evidence has shown that only around half of post-ACLR patients can expect to return to competitive level of sports. A rising concern is the high rate of second ACL injuries, particularly in young athletes, with up to 20% of those returning to sport in the first year from surgery experiencing a second ACL rupture. Aside from the increased risk of second injury, patients after ACLR have an increased risk of developing early onset of osteoarthritis. Given the recent findings, it is imperative that rehabilitation after ACLR is scrutinized so the second injury preventative strategies can be optimized. Unfortunately, current ACLR rehabilitation programs may not be optimally effective in addressing deficits related to the initial injury and the subsequent surgical intervention. Motor learning to (re-)acquire motor skills and neuroplastic capacities are not sufficiently incorporated during traditional rehabilitation, attesting to the high re-injury rates. The purpose of this article is to present novel clinically integrated motor learning principles to support neuroplasticity that can improve patient functional performance and reduce the risk of second ACL injury. The following key concepts to enhance rehabilitation and prepare the patient for re-integration to sports after an ACL injury that is as safe as possible are presented: (1) external focus of attention, (2) implicit learning, (3) differential learning, (4) self-controlled learning and contextual interference. The novel motor learning principles presented in this manuscript may optimize future rehabilitation programs to reduce second ACL injury risk and early development of osteoarthritis by targeting changes in neural networks.
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Context:Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%.Objectives:(1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes.Data Sources:PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature.Study Selection:Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies.Study Design:Scoping review.Level of Evidence:Level 4.Data Extraction:Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart.Results:Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported.Conclusion:RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.
DOCUMENT
Primary anterior cruciate ligament (ACL) injury prevention programs effectively reduce ACL injury risk in the short term. Despite these programs, ACL injury incidence is still high, making it imperative to continue to improve cur- rent prevention strategies. A potential limitation of current ACL injury prevention training may be a deficit in the transfer of conscious, optimal movement strategies rehearsed during training sessions to automatic movements required for athletic activities and unanticipated events on the field. Instructional strategies with an internal focus of attention have traditionally been utilized, but may not be optimal for the acquisition of the control of complex motor skills required for sports. Conversely, external-focus instructional strategies may enhance skill acquisition more efficiently and increase the transfer of improved motor skills to sports activities. The current article will present in- sights gained from the motor-learning domain that may enhance neuromuscular training programs via improved skill development and increased reten- tion and transfer to sports activities, which may reduce ACL injury incidence in the long term.
DOCUMENT
In societies where physical activity levels are declining, stimulating sports participation in youth is vital. While sports offer numerous benefits, injuries in youth are at an all-time high with potential long-term consequences. Particularly, women football's popularity surge has led to a rise in knee injuries, notably anterior cruciate ligament (ACL) injuries, with severe long-term effects. Urgent societal attention is warranted, supported by media coverage and calls for action by professional players. This project aims to evaluate the potential of novel artificial intelligence-based technology to enhance player monitoring for injury risk, and to integrate these monitoring pathways into regular training practice. Its success may pave the way for broader applications across different sports and injuries. Implementation of results from lab-based research into practice is hindered by the lack of skills and technology needed to perform the required measurements. There is a critical need for non-invasive systems used during regular training practice and allowing longitudinal monitoring. Markerless motion capture technology has recently been developed and has created new potential for field-based data collection in sport settings. This technology eliminates the need for marker/sensor placement on the participant and can be employed on-site, capturing movement patterns during training. Since a common AI algorithm for data processing is used, minimal technical knowledge by the operator is required. The experienced PLAYSAFE consortium will exploit this technology to monitor 300 young female football players over the course of 1 season. The successful implementation of non-invasive monitoring of football players’ movement patterns during regular practice is the primary objective of this project. In addition, the study will generate key insights into risk factors associated with ACL injury. Through this approach, PLAYSAFE aims to reduce the burden of ACL injuries in female football players.
