Hege Grindem

• Urhausen, Anouk; Grindem, Hege; Ingelsrud, Lina Holm; Roos, Ewa M.; Silbernagel, Karin Grävare & Snyder-Mackler, Lynn [Show all 7 contributors for this article] (2024). Patient Acceptable Symptom State Thresholds for IKDC-SKF and KOOS at the 10-Year Follow-up After Anterior Cruciate Ligament Injury: A Study From the Delaware-Oslo ACL Cohort. Orthopaedic Journal of Sports Medicine (OJSM). ISSN 2325-9671. 12(5). doi: 10.1177/23259671241250025.
• Urhausen, Anouk; Grindem, Hege; Engebretsen, Lars; Silbernagel, Karin Grävare; Axe, Michael J. & Snyder-mackler, Lynn (2024). The Delaware‐Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9–12 years after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. ISSN 0942-2056. doi: 10.1002/ksa.12039.
• Urhausen, Anouk; Grindem, Hege; Engebretsen, Lars; Grävare Silbernagel, Karin; Axe, Michael J. & Snyder-Mackler, Lynn [Show all 7 contributors for this article] (2024). The Delaware-Oslo ACL Cohort treatment algorithm yields superior outcomes to usual care 9-12 years after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy. ISSN 0942-2056. 32(2), p. 214–222. doi: 10.1002/ksa.12039.
• Holmgren, David; Noory, Shiba; Moström, Eva; Grindem, Hege; Stålman, Anders & Wörner, Tobias (2024). Weaker Quadriceps Muscle Strength With a Quadriceps Tendon Graft Compared With a Patellar or Hamstring Tendon Graft at 7 Months After Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine. ISSN 0363-5465. 52(1), p. 69–76. doi: 10.1177/03635465231209442. Full text in Research Archive
• Pedersen, Marie; Grindem, Hege; Berg, Bjørnar; Engebretsen, Lars; Axe, Michael J. & Snyder-Mackler, Lynn [Show all 7 contributors for this article] (2022). Four Distinct 5-Year Trajectories of Knee Function Emerge in Patients Who Followed the Delaware-Oslo ACL Cohort Treatment Algorithm. American Journal of Sports Medicine. ISSN 0363-5465. 50(11), p. 2944–2952. doi: 10.1177/03635465221116313. Full text in Research Archive Show summary

  Background: Impairments and dysfunction vary considerably after anterior cruciate ligament (ACL) injury, and distinct subgroups may exist. Purpose: (1) To identify subgroups of patients with ACL injury who share common trajectories of patient-reported knee function from initial presentation to 5 years after a treatment algorithm where they chose either ACL reconstruction (ACLR) plus rehabilitation or rehabilitation alone. (2) To assess associations with trajectory affiliation. Study Design: Cohort study; Level of evidence, 3. Methods: We included 276 patients with a acute first-time complete unilateral ACL injury. All patients underwent a 5-week neuromuscular and strength training program before a shared decision-making process about treatment. Within their latest attended follow-up, 62% of patients had undergone early ACLR (<6 months after the 5-week program), 11% delayed ACLR (>6 months after the 5-week program), and 27% progressive rehabilitation alone. Patients completed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF) at inclusion, after the 5-week program, and at 6 months, 1 year, 2 years, and 5 years after ACLR or completion of the 5-week program (patients treated with rehabilitation alone). We used group-based trajectory modeling to identify trajectories of IKDC-SKF and multinomial logistic regression to assess associations with trajectory affiliation. Results: Four distinct trajectories of IKDC-SKF were identified: Low (n = 22; 8.0% of the cohort), Moderate (n = 142; 51.4%), High (n = 105; 38.0%), and High Before Declining (n = 7; 2.5%). The High trajectory had higher scores at inclusion than the Moderate trajectory, but both improved considerably within 1 year and had thereafter stable high scores. The High Before Declining trajectory also started relatively high and improved considerably within 1 year but experienced a large deterioration between 2 and 5 years. The Low trajectory started low and had minimal improvement. New knee injuries were important characteristics of the High Before Declining trajectory, concomitant meniscal injuries were significantly associated with following the Low (vs Moderate) trajectory, and early/preoperative quadriceps strength and hop symmetry (measured at inclusion) were significantly associated with following the High (vs Moderate) trajectory. Conclusion: We identified 4 distinct 5-year trajectories of patient-reported knee function, indicating 4 subgroups of patients with ACL injury. Importantly, 88% of the patients who followed our treatment algorithm followed the Moderate and High trajectories characterized by good improvement and high scores. Due to eligibility criteria and procedures in our cohort, we can only generalize our model to athletes without major concomitant injuries who follow a similar treatment algorithm. Concomitant meniscal injuries and new knee injuries were important factors in the unfavorable Low and High Before Declining trajectories. These associations were exploratory but support the trajectories’ validity. Our findings can contribute to patient education about prognosis and underpin the importance of continued secondary injury prevention.

• Vlok, Arnold; van Dyk, Nicol; Coetzee, Derik & Grindem, Hege (2022). Exercise Descriptors That Determine Muscle Strength Gains Are Missing From Reported Anterior Cruciate Ligament Reconstruction Rehabilitation Programs: A Scoping Review of 117 Exercises in 41 Studies. Journal of Orthopaedic and Sports Physical Therapy. ISSN 0190-6011. 52(2), p. 100–112. doi: 10.2519/jospt.2022.10651. Show summary

  Objective: To (1) describe which strength training exercise descriptors are reported in anterior cruciate ligament reconstruction (ACLR) rehabilitation research, and (2) compare the current standards of reporting ACLR strength training exercise descriptors to international best-practice strength training guidelines. Design: Scoping review. Literature Search: We searched the MEDLINE, PsycINFO, CINAHL, SPORTDiscus, Academic Search, ERIC, Health Source: Nursing, Health Source: Consumer, MasterFILE, and Africa-Wide Information databases. Study Selection Criteria: We included level I to IV studies of ACLR rehabilitation programs with 1 or more reported strength training exercise descriptors. We used a predefined list of 19 exercise descriptors, based on the American College of Sports Medicine (ACSM) exercise recommendations, the Consensus on Exercise Reporting Template (CERT), and the Toigo and Boutellier exercise descriptor framework. Data Synthesis: Completeness and the standard of reporting exercise descriptors in ACLR rehabilitation programs were assessed by means of international best-practice strength training standards. Results: We extracted data on 117 exercises from 41 studies. A median of 7 of the 19 possible exercise descriptors were reported (range, 3–16). Reporting of specific exercise descriptors varied across studies, from 95% (name of the strength training exercise) to 5% (exercise aim, exercise order). On average, 46%, 35%, and 43% of the exercise descriptors included in the ACSM, CERT, and Toigo and Boutellier guidelines were reported, respectively. Conclusion: Key exercise descriptors for muscle strength gains are not reported in studies on ACLR rehabilitation. Only the exercise name, number of exercises, frequency, and experimental period were reported in most of the studies.

• Rønne Pedersen, Julie; Holst Hansen, Steffan; Grindem, Hege; Plauborg Jepsen, Anni & Thorlund, Jonas Bloch (2021). Readiness for return to sport in non-surgically treated patients with anterior cruciate ligament injury following a public municipal rehabilitation program. Physical Therapy in Sport. ISSN 1466-853X. 53, p. 7–13. doi: 10.1016/j.ptsp.2021.10.016. Full text in Research Archive Show summary

  Objectives: To investigate the proportion of patients that pass a return to sport (RTS) test battery and assess changes in patient-reported outcomes and lower extremity muscle strength following three months of exericse-based rehabilitation in non-surgically treated patients with anterior cruciate ligament (ACL) injury. Design: Prospective cohort study. Setting: Clinical environment (public municipal). Participants: Thirty-nine ACL injured patients (54% female, median age (IQR) 28 years (24–35). Main outcome measures: The Knee Injury and Osteoarthritis Outcome Score, Knee Outcome Survey Activities of Daily Living Scale, single hop for distance, crossover hop for distance, side hop test, the Agility T-test, and quadriceps and hamstrings isometric maximal voluntary contraction (MVC). Results: Following 3 months of rehabilitation, patients had statistically significant improvements in all patients-reported outcomes and in quadriceps and hamstring MVC. Of 28 patients who completed all RTS tests, 11% passed six RTS criteria, 14% five criteria, 11% four criteria, 4% three criteria, 18% two criteria, 21% one criterion, and 21% none of the criteria. Conclusions: The results suggest that three months of public municipal rehabilitation improves patient-reported outcomes and lower extremity muscle strength in non-surgically treated patients with ACL injury. However, only one in every 10 patients passed all RTS criteria.

• Richter, Chris; Petushek, Erich; Grindem, Hege; Franklyn-Miller, Andrew; Bahr, Roald & Krosshaug, Tron (2021). Cross-validation of a machine learning algorithm that determines anterior cruciate ligament rehabilitation status and evaluation of its ability to predict future injury. Sports Biomechanics. ISSN 1476-3141. doi: 10.1080/14763141.2021.1947358. Full text in Research Archive Show summary

  Classification algorithms determine the similarity of an observation to defined classes, e.g., injured or healthy athletes, and can highlight treatment targets or assess progress of a treatment. The primary aim was to cross-validate a previously developed classification algorithm using a different sample, while a secondary aim was to examine its ability to predict future ACL injuries. The examined outcome measure was ‘healthy-limb’ class membership probability, which was compared between a cohort of athletes without previous or future (No Injury) previous (PACL) and future ACL injury (FACL). The No Injury group had significantly higher probabilities than the PACL (p < 0.001; medium effect) and FACL group (p ≤ 0.045; small effect). The ability to predict group membership was poor for the PACL (area under curve [AUC]; 0.61<AUC<0.62) and FACL group (0.57<AUC<0.59). The ACL injury incidence proportion was highest in athletes with probabilities below 0.20 (9.4%; +2.7% to baseline), while athletes with probabilities above 0.80 had an incidence proportion of 4.1% (−2.6%). While findings that a low probability might represent an increase in injury risk on a group level, it is not sensitive enough for injury screening to predict a future injury on the individual level.

• Pedersen, Marie; Grindem, Hege; Johnson, Jessica L.; Engebretsen, Lars; Axe, Michael J. & Snyder-Mackler, Lynn [Show all 7 contributors for this article] (2021). Clinical, Functional, and Physical Activity Outcomes 5 Years Following the Treatment Algorithm of the Delaware-Oslo ACL Cohort Study. Journal of Bone and Joint Surgery. American volume. ISSN 0021-9355. 103(16), p. 1473–1481. doi: 10.2106/JBJS.20.01731. Show summary

  Background: Anterior cruciate ligament (ACL) injuries can be treated with or without ACL reconstruction (ACLR), and more high-quality studies evaluating outcomes after the different treatment courses are needed. The purpose of the present study was to describe and compare 5-year clinical, functional, and physical activity outcomes for patients who followed our decision-making and treatment algorithm and chose (1) early ACLR with preoperative and postoperative rehabilitation, (2) delayed ACLR with preoperative and postoperative rehabilitation, or (3) progressive rehabilitation alone. Early ACLR was defined as that performed ≤6 months after the preoperative rehabilitation program, and late ACLR was defined as that performed >6 months after the preoperative rehabilitation program. Methods: We included 276 patients from a prospective cohort study. The patients had been active in jumping, pivoting, and cutting sports before the injury and sustained a unilateral ACL injury without substantial concomitant knee injuries. The patients chose their treatment through a shared decision-making process. At 5 years, we assessed the International Knee Documentation Committee Subjective Knee Form (IKDC-SKF), Knee injury and Osteoarthritis Outcome Score (KOOS), Marx Activity Rating Scale, sports participation, quadriceps muscle strength, single-legged hop performance, and new ipsilateral and contralateral knee injuries. Results: The 5-year follow-up rate was 80%. At 5 years, 64% of the patients had undergone early ACLR, 11% had undergone delayed ACLR, and 25% had had progressive rehabilitation alone. Understandably, the choices that participants made differed by age, concomitant injuries, symptoms, and predominantly level-I versus level-II preinjury activity level. There were no significant differences in any clinical, functional, or physical activity outcomes among the treatment groups. Across treatment groups, 95% to 100% of patients were still active in some kind of sports and 65% to 88% had IKDC-SKF and KOOS scores above the threshold for a patient acceptable symptom state. Conclusions: Patients with ACL injury who were active in jumping, pivoting, and cutting sports prior to injury; who had no substantial concomitant knee injuries; and who followed our decision-making and treatment algorithm had good 5-year knee function and high sport participation rates. Three of 4 patients had undergone ACLR within 5 years. There were no significant differences in any outcomes among patients treated with early ACLR, delayed ACLR, or progressive rehabilitation alone.

• Moksnes, Håvard; Ardern, Clare L.; Kvist, Joanna; Engebretsen, Lars; Risberg, May Arna & Myklebust, Grethe [Show all 7 contributors for this article] (2021). Assessing implementation, limited efficacy, and acceptability of the BEAST tool: A rehabilitation and return-to-sport decision tool for nonprofessional athletes with anterior cruciate ligament reconstruction. Physical Therapy in Sport. ISSN 1466-853X. 52, p. 147–154. doi: 10.1016/j.ptsp.2021.08.011. Full text in Research Archive Show summary

  Objectives: To assess the implementation, limited efficacy, and acceptability of the BEAST (better and safer return to sport) tool – a rehabilitation and return-to-sport (RTS) decision tool after anterior cruciate ligament reconstruction (ACLR) in nonprofessional athletes. Design: Prospective cohort. Participants: 43 nonprofessional pivoting sport athletes with ACLR. Main outcome: Clinician- and athlete-experienced implementation challenges (implementation), changes in quadriceps power, side hop and triple hop performance from 6 to 8 months after ACLR (limited efficacy), athletes’ beliefs about the individual rehabilitation and RTS plans produced by the BEAST tool (acceptability). Results: The BEAST tool was developed and then implemented as planned for 39/43 (91%) athletes. Hop and quadriceps power performance improved significantly, with the largest improvement in involved quadriceps power (standardised response mean 1.4, 95% CI:1.1–1.8). Athletes believed the rehabilitation and RTS plan would facilitate RTS (8.2 [SD: 2.0]) and reduce injury risk (8.3 [SD: 1.2]; 0 = not likely at all, 10 = extremely likely). Conclusion: The BEAST tool was implemented with few challenges and adjustments were rarely necessary. Athletes had large improvements in quadriceps power and hop performance on the involved leg. Athletes believed that the individual rehabilitation and RTS plans produced by the tool would facilitate RTS and reduce injury risk.

• Pedersen, Marie; Grindem, Hege; Berg, Bjørnar; Gunderson, Ragnhild; Engebretsen, Lars & Axe, Michael J. [Show all 8 contributors for this article] (2021). Low Rates of Radiographic Knee Osteoarthritis 5 Years After ACL Reconstruction or Rehabilitation Alone: The Delaware-Oslo ACL Cohort Study. Orthopaedic Journal of Sports Medicine (OJSM). ISSN 2325-9671. 9(8), p. 1–10. doi: 10.1177/23259671211027530. Full text in Research Archive
• Arhos, Elanna K.; Thoma, Louise M.; Grindem, Hege; Logerstedt, David; Risberg, May Arna & Snyder-Mackler, Lynn (2020). Association of Quadriceps Strength Symmetry and Surgical Status with Clinical Osteoarthritis 5 Years after Anterior Cruciate Ligament Rupture. Arthritis care & research. ISSN 2151-464X. 74(3), p. 386–391. doi: 10.1002/acr.24479. Show summary

  Objective: The objective of this study was to examine the association of quadriceps strength symmetry and surgical status (ACL reconstruction or nonoperative management) with early clinical knee OA 5 years after ACL injury or reconstruction. Methods: 204/300 athletes were analyzed 5 years after ACL injury or reconstruction (ACLR). Quadriceps strength was measured and reported as a limb symmetry index. We identified participants with early clinical knee OA using criteria that two of four Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales score ≤85% (Luyten et al. 2018). We calculated odds ratios (OR) and 95% confidence intervals (CI) using logistic regression, adjusted for age, sex, meniscal injury, and BMI, to examine the associations between quadriceps strength and surgical status with clinical knee OA. Results: 21% of participants met KOOS criteria for clinical knee OA (Luyten et al. 2018). For every 1% increase in quadriceps limb symmetry index, there was 4% lower odds of clinical OA (adjusted OR 0.96, 95% CI 0.93‐0.99) at 5 years. Surgical status was not associated with clinical knee OA (adjusted OR 0.58, 95% CI 0.23, 1.50). Conclusions: More symmetrical quadriceps strength, but not surgical status, 5 years after ACL injury or reconstruction was associated with lower odds of clinical knee OA.

• Pedersen, Marie; Johnson, Jessica L; Grindem, Hege; Magnusson, Karin; Snyder-Mackler, Lynn & Risberg, May Arna (2020). Meniscus or Cartilage Injury at the Time of Anterior Cruciate Ligament Tear Is Associated With Worse Prognosis for Patient-Reported Outcome 2 to 10 Years After Anterior Cruciate Ligament Injury: A Systematic Review. Journal of Orthopaedic and Sports Physical Therapy. ISSN 0190-6011. 50(9), p. 490–502. doi: 10.2519/jospt.2020.9451. Show summary

  Objectives: (1) To assess prognostic factors for patient-reported outcome measures (PROMs) and physical activity 2 to 10 years after anterior cruciate ligament reconstruction (ACLR) or anterior cruciate ligament (ACL) injury, and (2) to assess differences in prognostic factors between patients treated with ACLR and with rehabilitation alone. Design: Prognosis systematic review. Literature Search: Systematic searches were performed in PubMed, Web of Science, and SPORTDiscus. Study Selection Criteria: We selected prospective cohort studies and randomized clinical trials that included adults or adolescents undergoing either ACLR or rehabilitation alone after ACL rupture. Studies had to assess the statistical association between potential prognostic factors (factors related to patient characteristics, injury, or knee symptoms/function measured at baseline or within 1 year) and outcomes (PROMs and physical activity). Data Synthesis: Our search yielded 997 references. Twenty studies met the inclusion criteria. Seven studies with low or moderate risk of bias remained for data synthesis. Results: Moderate-certainty evidence indicated that concomitant meniscus and cartilage injuries were prognostic factors for worse PROMs 2 to 10 years after ACLR. Very low–certainty evidence suggested that body mass index, smoking, and baseline PROMs were prognostic factors for worse outcome. Very low–certainty evidence suggested that female sex and a worse baseline Marx Activity Rating Scale score were prognostic factors for a worse Marx Activity Rating Scale score 2 to 10 years after ACLR. There was a lack of studies on prognostic factors after rehabilitation alone. Conclusion: Concomitant meniscus and cartilage injuries were prognostic factors for worse long-term PROMs after ACLR. The certainty was very low for other prognostic factors.

• Grindem, Hege; Engebretsen, Lars; Axe, Michael; Snyder-Mackler, Lynn & Risberg, May Arna (2020). Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury : the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine. ISSN 0306-3674. doi: 10.1136/bjsports-2019-100623. Full text in Research Archive Show summary

  Objective: To elucidate the relationships between age, return to level I sport (RTS) within the first postoperative year, passing RTS criteria and second anterior cruciate ligament (ACL) injury. Methods: In a prospective cohort study, 213 athletes were followed for 2 years after ACL reconstruction to record second ACL injuries. Independent variables were age, passing RTS criteria and level I RTS within the first postoperative year (vs later or no RTS). We defined passing RTS criteria as ≥90 on the Knee Outcome Survey — Activities of Daily Living Scale, global rating scale of function and quadriceps strength/hop test symmetry. Results: The follow-up rate was >87% for all outcomes. In multivariable analysis, level I RTS within the first postoperative year and passing RTS criteria were highly associated with second ACL injury (level I RTS HR: 6.0 (95% CI: 1.6 to 22.6), pass RTS criteria HR: 0.08 (95% CI: 0.01 to 0.6)), while age was not (age HR: 0.96 (95% CI: 0.89 to 1.04)). Athletes <25 years had higher level I RTS rates in the first postoperative year (60.4%) than older athletes (28.0%). Of those who returned to level I sport in the first postoperative year, 38.1% of younger and 59.1% of older athletes passed RTS criteria. Conclusion: High rates of second ACL injury in young athletes may be driven by a mismatch between RTS rates and functional readiness to RTS. Passing RTS criteria was independently associated with a lower second ACL rate. Allowing more time prior to RTS, and improving rehabilitation and RTS support, may reduce second ACL injury rates in young athletes with ACL reconstruction.

• Ekås, Guri Ranum; Ardern, Clare L.; Grindem, Hege & Engebretsen, Lars (2020). Evidence too weak to guide surgical treatment decisions for anterior cruciate ligament injury: a systematic review of the risk of new meniscal tears after anterior cruciate ligament injury. British Journal of Sports Medicine. ISSN 0306-3674. 54(9), p. 520–527. doi: 10.1136/bjsports-2019-100956. Show summary

  Objective: To investigate the risk of new meniscal tears after treatment for anterior cruciate ligament (ACL) injury, in children and adults with and without ACL reconstruction. Design: Prognosis systematic review (PROSPERO registration number CRD42016036788). Methods: We searched Embase, Ovid Medline, Cochrane, CINAHL, SPORTDiscus, PEDro and Google Scholar from inception to 3rd May 2018. Eligible articles included patients with ACL injury (diagnosis confirmed by MRI and/or diagnostic arthroscopy), reported the number of meniscal tears at the time of ACL injury diagnosis/start of treatment and reported the number of new meniscal tears that subsequently occurred. Articles with fewer than 20 patients at follow-up, and articles limited to ACL revision surgery or multi-ligament knee injuries were excluded. Two independent reviewers screened articles, assessed eligibility, assessed risk of bias and extracted data. We judged the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation (GRADE) working group methodology. Results Of 75 studies included in the systematic review, 54 studies with 9624 patients and 501 new meniscal tears were appropriate for quantitative analysis. Heterogeneity precluded data pooling. The risk of new meniscal tears was 0%–21% when follow-up was

• Ekås, Guri Ranum; Grindem, Hege & Engebretsen, Lars (2019). Kunnskapen om nye meniskskader etter fremre korsbåndsskade holder ikke mål for å kunne styre klinisk praksis, 2019: Høstmøteboken - vitenskapelig program og abstrakter. Norsk Ortopedisk Forening. ISSN 978-82-994275-1-7. p. 87–87.
• Ardern, Clare L.; Ekås, Guri Ranum; Grindem, Hege; Moksnes, Håvard; Anderson, Allen & Chotel, Franck [Show all 25 contributors for this article] (2019). 2018 International Olympic Committee consensus statement. Sports Orthopaedics and Traumatology. ISSN 0949-328X. 35(2), p. 98–122. doi: 10.1016/j.orthtr.2019.04.050.
• Tandberg, Alexander; Grindem, Hege; Wiig, Christian & Figved, Wender (2019). Knee sliced open by skate blade: Complete patellar tendon rupture in an elite long track speed skater. BMJ Case Reports. ISSN 1757-790X. 12(4). doi: 10.1136/bcr-2018-228611.
• Thoma, Louise M.; Grindem, Hege; Logerstedt, David; Axe, Michael; Engebretsen, Lars & Risberg, May Arna [Show all 7 contributors for this article] (2019). 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. American Journal of Sports Medicine. ISSN 0363-5465. 47(4), p. 807–814. doi: 10.1177/0363546519825500. Full text in Research Archive Show summary

  Background: Some athletes demonstrate excellent dynamic stability after anterior cruciate ligament (ACL) rupture and return tosport without ACL reconstruction (ACLR) (copers). Others demonstrate persistent instability despite rehabilitation (noncopers) andrequire surgical stabilization. Testing to determine coper classification can identify potential copers early after rupture. It is unclearhow 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 progressiveneuromuscular and strength training (NMST) among athletes early after acute ACL rupture and (2) to evaluate the association ofearly 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 enrolledearly after ACL rupture. Participants (n = 271) were tested and classified as potential copers or noncopers according to established cri-teria before and after a 10-session NMST program. Success 2 years after ACLR or nonoperative rehabilitation was defined as meeting orexceeding 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 characteristicswas 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 fol-low-up. The coper classifications were different between time points: nearly half of those classified initially as noncopers becamepotential 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 co-pers after NMST were more likely to succeed 2 years later regardless of whether they had surgery, strongly supporting the addi-tion of NMST before ACLR. Persistent noncopers fared poorly, indicating that more intensive rehabilitation may be needed.

• Ekås, Guri Ranum; Mjelde, Marit; Larmo, Arne Feilberg; Moksnes, Håvard; Grindem, Hege & Risberg, May Arna [Show all 7 contributors for this article] (2019). Knee Pathology in Young Adults After Pediatric Anterior Cruciate Ligament Injury: A Prospective Case Series of 47 Patients With a Mean 9.5-Year Follow-up. American Journal of Sports Medicine. ISSN 0363-5465. 47(7), p. 1557–1566. doi: 10.1177/0363546519837935. Show summary

  Background: The rate of secondary knee injuries after pediatric anterior cruciate ligament (ACL) injury is uncertain, and previous studies are limited because of poor methodology. Purpose: To evaluate the incidence of new meniscal injuries since the initial diagnostic magnetic resonance imaging (MRI) of young adults who sustained a pediatric ACL injury. In addition, to evaluate meniscal and cartilage injuries in the index knee and contralateral knee injuries on MRI at final follow-up (9.5 years). Furthermore, to assess leg length and alignment based on long-leg radiographs. Study Design: Case series; Level of evidence, 4. Methods: Study population at final follow-up included 47 young adults who sustained a pediatric ACL injury before age 13 years. They were followed prospectively since the time of injury for a mean 9.5 years at final follow-up. Imaging included diagnostic MRI of the index knee and 3.0-T MRI of both knees at 1-, 2-, and 9.5-year follow-up, in addition to long-leg radiographs at final follow-up. Forty-three patients underwent active rehabilitation without ACL reconstruction initially; 4 were treated with initial ACL reconstruction. At final follow-up, 27 (57%) had undergone ACL reconstruction. Results: Fourteen patients had meniscal tears in the index knee at final follow-up (prevalence, 30%). The majority of these were in the same location as previously repaired tears (n = 9). Between diagnostic MRI and final follow-up, 16 patients had sustained new meniscal tears to a healthy meniscus (incidence, 34%). At final follow-up, meniscal injuries recorded at baseline or during follow-up were no longer visible and appeared healed in 17 patients (20 tears). MRI at final follow-up showed cartilage injuries in the index knee of 13 patients (28%) and contralateral injuries in 8 patients (meniscus, n = 2; cartilage, n = 5; subchondral fracture, n = 1). Two patients had a leg-length difference >15 mm, and 3 had side-to-side difference in knee alignment >5°. Conclusion: The incidence of new meniscal tears after pediatric ACL injury was 34% during a mean follow-up period of 9.5 years. At final follow-up, 27 patients (57%) had normal menisci, and none had developed knee osteoarthritis. Primary active rehabilitation, close follow-up, and delayed surgery if needed may be a viable and safe treatment option for some pediatric ACL injuries.

• Filbay, Stephanie R & Grindem, Hege (2019). Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Baillière's Best Practice & Research : Clinical Rheumatology. ISSN 1521-6942. p. 1–15. doi: 10.1016/j.berh.2019.01.018. Full text in Research Archive Show summary

  Anterior cruciate ligament (ACL) rupture occurs most commonly in young and active individuals and can have negative long-term physical and psychological impacts. The diagnosis is made with a combination of patient's history, clinical examination, and, if appropriate, magnetic resonance imaging. The objectives of management are to restore knee function, address psychological barriers to activity participation, prevent further injury and osteoarthritis, and optimize long-term quality of life. The three main treatment options for ACL rupture are (1) rehabilitation as first-line treatment (followed by ACL reconstruction (ACLR) in patients, who develop functional instability), (2) ACLR and post-operative rehabilitation as the first-line treatment, and (3) pre-operative rehabilitation followed by ACLR and post-operative rehabilitation. We provide practical recommendations for informing and discussing management options with patients, and describe patient-related factors associated with a worse ACL-rupture outcome. Finally, we define evidence-based rehabilitation and present phase-specific rehabilitation recommendations and criteria to inform return to sport decisions.

• Ekås, Guri Ranum; Moksnes, Håvard; Grindem, Hege; Risberg, May Arna & Engebretsen, Lars (2019). Coping With Anterior Cruciate Ligament Injury From Childhood to Maturation: A Prospective Case Series of 44 Patients With Mean 8 Years’ Follow-up. American Journal of Sports Medicine. ISSN 0363-5465. 47(1), p. 22–30. doi: 10.1177/0363546518810750. Full text in Research Archive Show summary

  Background: There is no consensus regarding the best treatment approach for skeletally immature children with anterior cruciate ligament (ACL) injuries. High-quality studies with long-term follow-up are lacking, and evidence to support decision making is limited. Purpose: To evaluate functional and patient-reported outcome, surgical history, and complications among young adults who sustained an ACL injury before the age of 13 years and were treated with active rehabilitation and the option of delayed ACL reconstruction if needed. Study Design: Case series; Level of evidence, 4. Methods: Forty-six children aged <13 years with a total intrasubstance ACL injury were included. None of these patients had additional injuries that warranted early surgery. At final follow-up at a mean 8 years after the time of injury, 44 patients remained in the study. The same test battery was conducted at baseline, 1 and 2 years, and final follow-up at approximately 18 years of age. The test battery included functional tests (hop tests and isokinetic muscle strength tests of quadriceps and hamstrings), patient-reported outcome measures (including the Knee injury and Osteoarthritis Outcome Score and the International Knee Documentation Committee Subjective Knee Form), and clinical examination. Medical records were reviewed to assess surgical history and complications. Results: At a mean 8 years of follow-up, 24 patients (55%) had undergone ACL reconstruction, and 16 (36%) had undergone meniscal surgery. Quadriceps muscle strength symmetry was >90% for 30 patients (68%). Mean leg symmetry indexes for hop and strength tests were consistently >90%, except for the single-hop test and hamstrings muscle strength for ACL-reconstructed knees. Mean ± SD International Knee Documentation Committee scores were 86.3 ± 13.7 for the ACL-reconstructed knees and 90.6 ± 11.8 for the nonreconstructed knees. At final follow-up, forty patients (91%) remained active in sports, but 29 (66%) restricted their activity level to nonpivoting sports. Conclusion: Active rehabilitation may have a role in treatment of children with ACL injury. Approximately 50% of children may cope well, even to adulthood, without a surgical intervention. The other half may develop instability that warrants ACL reconstruction, and one-third may require meniscal surgery.

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