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The patellofemoral pain syndrome (PFPS) is a possible cause for anterior knee pain, which predominantly affects young female patients without any structural changes such as increased Q-angle or significant chondral damage. This literature review has shown that PFPS development is probably multifactorial with various functional disorders of the lower extremity. Biomechanical studies described patellar maltracking and dynamic valgus in PFPS patients (functional malalignment). Causes for the dynamic valgus may be decreased strength of the hip abductors or abnormal rear-foot eversion with pes pronatus valgus. PFPS is further associated with vastus medialis/vastus lateralis dysbalance, hamstring tightness or iliotibial tract tightness. The literature provides evidence for a multimodal non-operative therapy concept with short-term use of NSAIDs, short-term use of a medially directed tape and exercise programmes with the inclusion of the lower extremity, and hip and trunk muscles. There is also evidence for the use of patellar braces and foot orthosis. A randomized controlled trial has shown that arthroscopy is not the treatment of choice for treatment of PFPS without any structural changes. Patients with anterior knee pain have to be examined carefully with regard to functional causes for a PFPS. The treatment of PFPS patients is non-operative and should address the functional causes. Level of evidence V.

Anterior knee pain is one of the most common causes of persistent problems after implantation of a total knee replacement. It can occur in patients with or without patellar resurfacing. As a result of the surgical procedure itself many changes can occur which may affect the delicate interplay of the joint partners in the patello-femoral joint. Functional causes of anterior knee pain can be distinguished from mechanical causes. The functional causes concern disorders of inter- and intramuscular coordination, which can be attributed to preoperative osteoarthritis. Research about anterior knee pain has shown that not only the thigh muscles but also the hip and trunk stabilising muscles may be responsible for the development of a dynamic valgus malalignment. Dynamic valgus may be a causative factor for patellar maltracking. The mechanical causes of patello-femoral problems after knee replacement can be distinguished according to whether they increase instability in the joint, increase joint pressure or whether they affect the muscular lever arms. These causes include offset errors, oversizing, rotational errors of femoral or tibial component, instability, maltracking and chondrolysis, patella baja and aseptic loosening. In these cases, reoperation or revision is often necessary.

To find contributors to return to sport success or time until return to sport in individuals after an anterior cruciate ligament reconstruction. Cohort study. Secondary analysis of the data of two intervention studies. We included adults < 36 years of age with a tendon autograft anterior cruciate ligament reconstruction who were active in any type of sport prior to the injury and aiming to return to sport. All participants were prospectively monitored for 24 months. At the end of the individual post-surgery rehabilitation and re-injury prevention programmes, self-report- and objective functional outcomes were quantified. The potential return to sport success (return to the same type of sports, frequency, intensity, and quality of performance as pre-injury), secondary injuries, and all rehabilitation and training measures were prospectively monitored. To determine the contributing factors, Cox regressions for traits and baseline factors and a logistic mixed model, which also included prospective time-dependent factors, were calculated. 203 participants were included; 104 (51 % of the total sample and 68 % of the full cases) successfully returned to their sporting activity. The median duration until return to sport was 302 days (interquartile range was 114 days). Contributing factors were the type of working (blue- vs. white collar: odds ratio for return to sport = 0.51 [95 % confidence interval = 0.29 to 0.90]) and the athletic status (elite vs. non-elite: odds ratio = 2.28 [1.03 to 5.03]). Prospectively, higher rehabilitation volumes until the end of the rehabilitation were predictive for return to sport success: the odds ratio per additional hour of rehabilitation was 1.004 [1.001 to 1.006]. Functional abilities such as the normalised knee separation distance during drop jump landing (odds ratio = 0.961 [0.924 to 0.999]) were predictive at a later stage, at the end of the re-injury prevention. Psychological readiness for return to sport was predictive at most of the timepoints: those who were confident to return to sport were more successful to return to sport at the end of the rehabilitation (odds ratio = 1.029 [1.004 to 1.056]) and at the end of the re-injury prevention (odds ratio = 1.038 [1.004 to 1.073]). The most important factors for a successful pre-injury-level return to sport after anterior cruciate ligament reconstruction were the exercise volume, psychological readiness and functional hop/jump abilities. Whilst the impact of these modifiable factors was robust against multilevel modelling, the impact of athletic and working status vanishes when the prospective factors are included.

Background: Different indications and treatment options for combined injuries to the anterior cruciate ligament (ACL) and medial collateral ligament complex (MCL) are not clearly defined. Purpose: To perform a modified Delphi process with the Committee for Ligament Injuries of the German Knee Society (DKG) in order to structure and optimize the process of treating a combined injury to the ACL and MCL. Study Design: Consensus statement. Methods: Scientific questions and answers were created based on a comprehensive literature review using the central registers for controlled studies of Medline, Scopus, and Cochrane including the terms medial collateral ligament, anterior cruciate ligament, MCL, ACL, and outcome used in various combinations. The obtained statements passed 3 cycles of a modified Delphi process during which each was readjusted and rated according to the available evidence (grades A-E) by the members of the DKG Ligament Injuries Committee and its registered guests. Results: The majority of answers, including several questions with >1 graded answer, were evaluated as grade E (n = 16) or C (n = 10), indicating that a low level of scientific evidence was available for most of the answers. Only 5 answers were graded better than C: 3 answers with a grade of A and 2 answers with a grade of B. Only 1 answer was evaluated as grade D. An agreement of >80% (range, 83%-100%) among committee members was achieved for all statements. Conclusion: The results of this modified Delphi process offer a guideline for standardized patient care in cases of combined injuries to the ACL and MCL.

Background: Information derived from functional return-to-sport (RTS) tests after primary anterior cruciate ligament (ACL) reconstruction (ACLR) can have a significant impact on the risk reduction of ACL reruptures. However, due to space, time, and financial limitations, few clinicians utilize objective data to assess their patients’ functional abilities after ACLR. Purpose: To identify validated and feasible RTS tests that could reliably estimate the risk of reinjury after ACLR in everyday clinical practice beyond the highly sophisticated laboratory setting. Study Design: Systematic review; Level of evidence, 4. Methods: A focused review was performed by experts of the committees for Ligament Injuries and Prevention/Rehabilitation of the German Knee Society. RTS functional tests, their reinjury prognostic values (if known), their reliabilities, and their implementation capacities were extracted from the original studies on the described RTS test setup, as well as from studies on potential test alternatives. These alternatives were required to be less resource-consuming yet still validated and thus able to be implemented into everyday practice. All tests were categorized according to their relevant target objective: isokinetic or isometric strength, functional (hopping and jumping) ability, or self-reported readiness. Results: In the final analysis, 19 studies involving 7513 patients were included. From these, a total of 21 RTS tests were retrieved, and 13 tests were included. For strength testing, 2 dynamic tests and 1 static test were found to be eligible. Functional ability was represented by 8 different jump, hop, and agility tests. Tests for self-reported readiness included the ACL–Return to Sport after Injury scale and the Knee injury and Osteoarthritis Outcome Score Sport and Recreation subscore. Alternative tests included the 8–repetition maximum test, handheld/portable dynamometer, single-leg vertical (countermovement) hop with inertial sensor or smartphone app, and the drop jump with knee displacement or normalized knee distance measurement. Conclusion: For most of the strength and functional abilities assessed by RTS tests, validated and less resource-consuming alternatives do exist. Therapists and clinicians working in nonlaboratory settings may find it helpful to select from a menu of established RTS tests and test alternatives for each relevant target objective, depending on their individual requirements.

Aims and Objectives: Ruptures of the anterior cruciate ligament in childhood and adolescence are severe injuries with increasing incidence over the last years. It is known today that the course of an unstable knee joint during growth can lead to poor subjective and objective results. The aim of the study is to record long-term results after transepiphyseal ACL reconstruction using autologous hamstring tendons and extracortical fixation in children and adolescents at least 15 years after surgery. Materials and Methods: We retrospectively evaluated patient who underwent ACL reconstruction in our clinic with arthroscopic transepiphyseal technique using hamstrings graft in childhood or adolescence with a follow-up of at least 15 years. In these patients, the Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner Activity Score (TAS), and Lysholm Score were collected, and clinical and MRI examinations were performed. Results: A total of 32 patients were identified, 5 of whom refused to participate. The average age at the time of surgery was 12 years, the average follow-up time was 17 years. In 3 patients a traumatic re-rupture was observed. None of the included patients showed a growth disorder at follow-up. The following subscores were found for the KOOS: KOOSpain 89, KOOSSymptom 82, KOOSADL 92, KOOSSport 75, KOOSQOL 82. The Tegner Activity score was 5.8, the Lysholm score 86 points. 13 of the 27 patients could also be examined clinically and by magnetic resonance imaging. In the MRI images, 95% of the patients showed intact grafts without evidence of cartilage or meniscus damage. The average lateral difference in the KT-1000 measurement was 1.5 mm. Conclusion: Transepiphyseal ACL reconstruction in children and adolescent with hamstrings is a save procedure leading to good long-term results. Secondary arthrosis signs can only be detected sporadically in MRI

Objectives: Meniscus injuries are a common cause of knee dysfunction, often requiring surgical intervention such as meniscus repair or meniscectomy. They also frequently occur as concomitant injury in anterior cruciate ligament (ACL) ruptures. Effective pre- and postoperative rehabilitation is critical for optimizing outcomes, yet access to timely physiotherapy can be limited. Digital health applications offer a promising solution to enhance patient education and rehabilitation continuity. This prospective multicenter randomized controlled trial (RCT) evaluates the efficacy of a digital health application (Orthopy) combined with standard care compared to standard care alone in patients with meniscus and ACL injuries. Methods: Patients aged 18 years or older with a confirmed diagnosis of isolated or concomitant meniscus injury and planned surgical intervention were enrolled between 10/2023 and 02/2025 at 4 different study sides (n=304). Patients with a Knee Injury and Osteoarthritis Outcome Scores (KOOS) of ≤ 85 across all subscales indicating significant knee dysfunction (n=227) before surgery were included in this analysis. Patients were randomized to either the intervention group (Orthopy app plus standard of care, including conventional orthopedic and physiotherapeutic measures) or the control group (standard of care alone). Baseline data (t0) were collected, followed by a pre-surgery period (2–6 weeks) and a post-surgery period (14 weeks). Interim assessments occurred via online questionnaires at t1 (if >2 weeks pre-surgery), t3, t4, and t5 (post-surgery), with clinical evaluations at t1 (pre-surgery) and t5 (14 weeks post-surgery). The primary outcome was the KOOS Symptoms and Function, with secondary outcomes including other KOOS subscales (pain/ ADL/ QoL) as well as subjective pain and function assessed via the Visual Analogue Scale (VAS). The analysis was conducted using mixed model repeated measures (MMRM), and the results are presented as estimated marginal means (EMM). Results: The intervention group (gender: 40 f, 64 m; age: 47 ± 16 years), using the Orthopy app alongside standard of care, demonstrated an EMM improvement of 23.8 points in the KOOS Symptoms subscale at t5 and thus a significantly greater improvement compared to the control group (gender: 51 f, 72 m; age: 45 ± 15 years) with a EMM between-group difference of 5.5 points (p = 0.016). Secondary outcomes at final follow-up, namely KOOS pain and VAS pain, further supported the superiority of the digital intervention, with an EMM difference of 4.65 (p = 0.047) for KOOS pain and -0.74 (p = 0.003) for VAS pain. Significant reductions in pain and symptoms were also observed at multiple time points. Conclusion: Integrating the Orthopy app with standard care enhances post-operative outcomes in patients with isolated and concomitant meniscus injuries, offering a safe and effective tool to support rehabilitation compared to standard of care alone.

Numerous functional factors may interactively contribute to the course of self-report functional abilities after anterior cruciate ligament  (ACL)-reconstruction. This study purposes to identify these predictors using exploratory moderation-mediation models in a cohort study design. Adults with post unilateral ACL reconstruction (hamstring graft) status and who were aiming to return to their pre-injury type and level of sport were included. Our dependent variables were self-reported function, as assessed by the the KOOS subscales sport (SPORT), and activities of daily living (ADL). The independent variables assessed were the KOOS subscale pain and the time since reconstruction [days]. All other variables (sociodemographic, injury-, surgery-, rehabilitation-specific, kinesiophobia (Tampa Scale of Kinesiophobia), and the presence or absence of COVID-19-associated restrictions) were further considered as moderators, mediators, or co-variates. Data from 203 participants (mean 26 years, SD 5 years) were finally modelled. Total variance explanation was 59% (KOOS-SPORT) and 47% (KOOS-ADL). In the initial rehabilitation phase (< 2 weeks after reconstruction), pain was the strongest contributor to self-report function (KOOS-SPORT: coefficient: 0.89; 95%-confidence-interval: 0.51 to 1.2 / KOOS-ADL: 1.1; 0.95 to 1.3). In the early phase (2–6 weeks after reconstruction), time since reconstruction [days] was the major contributor (KOOS-SPORT: 1.1; 0.14 to 2.1 / KOOS-ADL: 1.2; 0.43 to 2.0). Starting with the mid-phases of the rehabilitation, self-report function was no longer explicitly impacted by one or more contributors. The amount of rehabilitation [minutes] is affected by COVID-19-associated restrictions (pre-versus-post: − 672; − 1264 to − 80 for SPORT / − 633; − 1222 to − 45 for ADL) and by the pre-injury activity scale (280; 103 to 455 / 264; 90 to 438). Other hypothesised contributors such as sex/gender or age were not found to mediate the time or pain, rehabilitation dose and self-report function triangle. When self-report function is rated after an ACL reconstruction, the rehabilitation phases (early, mid, late), the potentially COVID-19-associated rehabilitation limitations, and pain intensity should also be considered. As, for example, pain is the strongest contributor to function in the early rehabilitation phase, focussing on the value of the self-report function only may, consequently, not be sufficient to rate bias-free function.

This is the first study examining functionality of subjects with anterior cruciate ligament (ACL) tears and a subsequent reconstruction comprehensively by multiple test sessions from pre- to six months post-reconstruction. The purpose was to evaluate if a generally applied rehabilitation program restores functionality to levels of healthy controls. Subjects with unilateral tears of the ACL were compared to matched healthy controls throughout the rehabilitation. 20 recreational athletes were tested: T1 (preoperative), 6 weeks after tear; T2, 6 weeks, T3, 3 months, T4, 6 months post-reconstruction. At all test sessions, subjects self-evaluated their activity level with the Tegner activity score and their knee state with the Knee Injury and Osteoarthritis Outcome Score. Passive range of motion during knee flexion and extension and leg circumference were measured as functional clinical tests. Bilateral countermovement jumps, one-leg jumps for distance and isometric force tests in knee flexion and extension with 90° and 110° knee angle were conducted as functional performance tests. For determination of functionality, leg symmetry indices (LSIs) were calculated by dividing values of the injured by the uninjured leg. In the ACL group most LSIs decreased from T1 to T2, and increased from T2 and T3 to T4. LSIs of ACL subjects remained lower than LSIs of healthy controls at 6 months post-reconstruction in nearly all parameters. Self-evaluation of ACL subjects showed, additionally, that activity level was lower than the pre-injury level at 6 months post-reconstruction. Low LSIs and low self-evaluation indicate that knee joint functionality is not completely restored at 6 months post-reconstruction. The study shows that multiple comprehensive testing throughout the rehabilitation gives detailed images of the functional state. Therefore, the functional state of ACL reconstructed individuals should be evaluated comprehensively and continuously throughout the rehabilitation to detect persisting deficiencies detailed and adapt rehabilitation programs individually depending on the functionality.

Background Although anterior cruciate ligament (ACL) tear-prevention programs may be effective in the (secondary) prevention of a subsequent ACL injury, little is known, yet, on their effectiveness and feasibility. This study assesses the effects and implementation capacity of a secondary preventive motor-control training (the Stop-X program) after ACL reconstruction. Methods and design A multicenter, single-blind, randomized controlled, prospective, superiority, two-arm design is adopted. Subsequent patients (18–35 years) with primary arthroscopic unilateral ACL reconstruction with autologous hamstring graft are enrolled. Postoperative guideline rehabilitation plus Classic follow-up treatment and guideline rehabilitation plus the Stop-X intervention will be compared. The onset of the Stop-X program as part of the postoperative follow-up treatment is individualized and function based. The participants must be released for the training components. The endpoint is the unrestricted return to sport (RTS) decision. Before (where applicable) reconstruction and after the clearance for the intervention (aimed at 4–8 months post surgery) until the unrestricted RTS decision (but at least until 12 months post surgery), all outcomes will be assessed once a month. Each participant is consequently measured at least five times to a maximum of 12 times. Twelve, 18 and 24 months after the surgery, follow-up-measurements and recurrence monitoring will follow. The primary outcome assessement (normalized knee-separation distance at the Drop Jump Screening Test (DJST)) is followed by the functional secondary outcomes assessements. The latter consist of quality assessments during simple (combined) balance side, balance front and single-leg hops for distance. All hop/jump tests are self-administered and filmed from the frontal view (3-m distance). All videos are transferred using safe big content transfer and subsequently (and blinded) expertly video-rated. Secondary outcomes are questionnaires on patient-reported knee function, kinesiophobia, RTS after ACL injury and training/therapy volume (frequency – intensity – type and time). All questionnaires are completed online using the participants’ pseudonym only. Group allocation is executed randomly. The training intervention (Stop-X arm) consists of self-administered home-based exercises. The exercises are step-wise graduated and follow wound healing and functional restoration criteria. The training frequency for both arms is scheduled to be three times per week, each time for a 30 min duration. The program follows current (secondary) prevention guidelines. Repeated measurements gain-score analyses using analyses of (co-)variance are performed for all outcomes. Trial registration German Clinical Trials Register, identification number DRKS00015313 . Registered on 1 October 2018.