Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts

Jacob J. Capin, Mathew Failla, Ryan Zarzycki, Celeste Dix, Jessica L. Johnson, Angela H. Smith, May Arna Risberg, Laura J. Huston, Kurt P. Spindler, Lynn Snyder-Mackler

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Background: Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential. Purpose: (1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo). Study Design: Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3. Methods: A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes. Results: No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores (P <.01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS–Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON (P =.011). Conclusion: Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR. Registration: NCT01773317 ( identifier).

Original languageEnglish (US)
JournalOrthopaedic Journal of Sports Medicine
Issue number8
StatePublished - Aug 2019
Externally publishedYes

Bibliographical note

Funding Information:
*Address correspondence to Jacob J. Capin, PT, DPT, PhD, 540 South College Avenue, Suite 210-Z, Newark, DE 19711, USA (email: (Twitter: @JacobCapin). †Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA. ‡Department of Physical Therapy, University of Delaware, Newark, Delaware, USA. §Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA. kDepartment of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA. {Department of Sport Medicine, Norwegian School of Sports Sciences, Oslo, Norway. #Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway. **Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA. ††Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: Funding provided by the National Institutes of Health: NIH/NIAMS Grant No. R01 AR048212 (L.S.-M.) for the ACL-SPORTS trial; NIH/NICHD Grant No. R37 HD037985 (L.S.-M.) for the Delaware-Oslo Cohort; NIH/NIAMS Grant No. R01 AR053684 (K.P.S.) for the MOON Cohort; and NIH/NICHD Grant No. F30 HD096830 (J.J.C.) for the NRSA predoctoral fellowship award. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. J.J.C.’s work was supported in part by the Foundation for Physical Therapy Promotion of Doctoral Studies, Level I and Level II Scholarships. K.P.S. has received consulting fees from Cytori, the National Football League, and Mitek; research support from Smith & Nephew Endoscopy and DonJoy Orthopaedics; and hospitality payments from DePuy and Biosense Webster. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto. Ethical approval for this study was obtained from the University of Delaware and Vanderbilt University Human Research Protections Program.

Funding Information:
The authors thank Kathleen Cummer, Amelia J.H. Arundale, Elizabeth Wellsandt, and Hege Grindem for their assistance with data collection; Martha Callahan and the Delaware Rehabilitation Institute for assistance with participant recruitment and retention; the University of Delaware Physical Therapy Clinic; and all participants for their involvement in this work.

Publisher Copyright:
© The Author(s) 2019.


  • anterior cruciate ligament (ACL)
  • female athlete
  • functional outcomes
  • physical therapy/rehabilitation
  • return-to-sport training


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