PDF Physical Therapy in Sport 2024 - A Survey of Swiss Physiotherapists

Physical Therapy in Sport 65 (2024) 38–48 Contents lists available at ScienceDirect Physical Th...

Physical Therapy in Sport 65 (2024) 38–48 Contents lists available at ScienceDirect Physical Therapy in Sport journal homepage: www.elsevier.com/ptsp Original Research Clinical practice and barriers among Swiss physiotherapists treating patients with anterior cruciate ligament reconstruction: A survey of pre-operative rehabilitation to return to sport Mathieu Pulver a, b, *, Roger Hilfiker c, Mario Bizzini d, Nicolas Mathieu e, Stephan Meyer f, Lara Allet b, g, h a Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland b School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, HES-SO Valais-Wallis, Sion, Switzerland c Physiotherapy Tschopp & Hilfiker, Glis, Switzerland d Schulthess Clinic Human Performance Lab, Zurich, Switzerland e School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, HES-SO Valais-Wallis, Leukerbad, Switzerland f Sport Physiotherapy, Swiss Federal Institute of Sport Magglingen SFISM, Magglingen, Switzerland g The Sense, Innovation & Research Center, Sion, Switzerland h Department of Medicine, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland A R T I C L E I N F O A B S T R A C T Handling Editor: Dr L Herrington Objectives: To investigate current clinical practice of Swiss physiotherapists treating patients with anterior cru­ ciate ligament reconstruction (ACLR) from pre-operative rehabilitation until return to sport (RTS). We assessed Keywords: optimisation strategies in daily practice and the perceived barriers to these optimisations, and evaluated whether Anterior cruciate ligament reconstruction there was a relevant difference in clinical practice for physiotherapists with post-graduate certification in sports Rehabilitation physiotherapy or deep clinical experience and those without such experience. Physical therapy Design: Cross-sectional survey. Survey Setting: Online survey platform. Participants: Swiss physiotherapists. Main outcome measures: The survey comprised six sections: participant information, pre-operative rehabilitation, post-operative rehabilitation, RTS, re-injury prevention, and optimisation strategies and barriers. Results: A minority of physiotherapists treated ACLR patients pre-operatively. Overall, 91% included quadriceps open kinetic chain exercise in their treatment, 37% used patient-reported outcomes measures (PROMs) and 39% considered psychological criteria when making decisions about RTS. Most physiotherapists (67%) felt limited due to the time available, the number of prescriptions and the tariffication system. Conclusion: This study highlights areas within ACLR rehabilitation practice in Switzerland that could be improve. Improvements in understanding of the barriers to implementation of best evidence in practice and a redefinition of the clinical process around ACLR rehabilitation in Switzerland are necessary. 1. Introduction expect to return to sport (RTS) at the pre-injury level (Feucht et al., 2016; Webster & Feller, 2019). However, Ardern et al. reported that Anterior cruciate ligament (ACL) tear is a common sports injury, only 33% returned to competition at the pre-injury level at 12 months, which hinders athletes from returning to their sports activity. Although and only 67% returned to sports participation overall (Ardern, Webster, conservative treatment is an acceptable option in some cases, surgery is Taylor, & Feller, 2011). Over a longer period, only 65% returned to generally recommended for patients involved in sports that involve pre-injury level, and 55% returned to competition (Ardern et al., jumping, cutting or pivoting movements, such as football (Diermeier 2014b). Alarmingly, the risk of sustaining a second ACL injury (ipsilat­ et al., 2020). Approximately 90% of patients who sustain an ACL rupture eral or contralateral) is high, with re-injury rates ranging between 15 * Corresponding author. Effingerstrasse 94, 3008, Bern, Switzerland. E-mail address: [email protected] (M. Pulver). https://doi.org/10.1016/j.ptsp.2023.10.007 Received 26 June 2023; Received in revised form 30 October 2023; Accepted 31 October 2023 Available online 7 November 2023 1466-853X/© 2023 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 and 23%, depending on age and whether they returned to sport (Wiggins 2. Methods et al., 2016). Although some evidence-based guidelines and treatment protocols 2.1. Participants and study design exist for ACL injuries, as yet there is no specific, detailed consensus on the optimal rehabilitation content after anterior cruciate ligament Physiotherapists currently working in Switzerland were invited to reconstruction (ACLR) (Logerstedt et al., 2017; Shea & Carey, 2015; van participate in this cross-sectional survey study. Inclusion criteria were: Melick et al., 2016; Wright et al., 2015). Although the general level of ability to understand at least one of the most common national lan­ evidence for ACLR rehabilitation is low (Whittaker et al., 2022), phys­ guages of Switzerland (French, German and Italian), having at least one iotherapists should comply with current guidelines for ACLR and RTS in year of experience in treating ACLR patients, and one patient per year. order to achieve “good clinical practice” when treating ACLR patients. For example, supported by moderate evidence, quadriceps strength can 2.2. Survey development be improved by using both open and closed kinetic chain exercises (Whittaker et al., 2022). There is general agreement in the current The questionnaire was initially developed in French, based on cur­ literature that rehabilitation after injury is a continuum process, rent evidence and questionnaires from other studies (Aquino et al., requiring shared decision-making throughout. Assessment of both 2020; Dingenen et al., 2021; Ebert et al., 2019; Greenberg et al., 2018). physical condition and psychological readiness; for example, by using The content of the questionnaire was evaluated by three experts with patient-reported outcome measures (PROMs), is generally recom­ extensive experience in practice and research in the field of sports mended throughout rehabilitation to achieve successful RTS (Ardern physiotherapy (two had a MSc and one a PhD). After the three experts et al., 2016; Davies, McCarty, Provencher, & Manske, 2017; Diermeier reached a consensus, the revised survey was pilot-tested on 12 physio­ et al., 2020; Dingenen & Gokeler, 2017; Gokeler, Dingenen, Mouton, & therapists, who evaluated the proper functioning of the electronic sur­ Seil, 2017; Gokeler et al., 2017; Kyritsis, Bahr, Landreau, Miladi, & vey, the sequence and clarity of the questions, linguistic issues, and the Witvrouw, 2016; Meredith et al., 2020). In addition to knowledge about time needed to complete the survey. After some minor adjustments how to treat patients with ACLR, there is also general consensus in the (related only to linguistic issues), the survey was then definitively literature on how to judge readiness for RTS after a sports injury (Ardern translated by native speakers into German and Italian (see Supplemen­ et al., 2016). However, there remains a need to determine the best RTS tary Material for survey development flowchart). testing battery for ACLR (Meredith et al., 2020). The main issue around The survey had different branching logics and was divided into the ACLR rehabilitation practice is thus not so much the knowledge of how following sections: (1) participant information; (2) treatment content of to treat ACLR, but rather the ease of implementation of evidence in daily pre-operative rehabilitation; (3) treatment content and progression of practice (Andrade, Pereira, van Cingel, Staal, & Espregueira-Mendes, post-operative rehabilitation; (4) criteria and decision-making for RTS; 2020). (5) use of injury prevention program to prevent re-injury; (6) optimi­ Indeed, studies of physiotherapists treating patients with ACLR in the sation strategies and barriers to these optimisations. An English version USA, Australia, Brazil, Belgium, Greece and New Zealand found wide of the questionnaire is available in the Supplementary Material. variability in clinical practice, and discrepancies between practice and Our study was exempted from submission by the local medical ethics current evidence-based treatment recommendations (Aquino et al., committee, as no identifiable data were collected (Req-2021-00705, 2020; Dingenen et al., 2021; Ebert et al., 2019; Fausett, Reid, & Larmer, 2021-05-14). 2022; Greenberg, Greenberg, Albaugh, Storey, & Ganley, 2018; Kor­ akakis, Kotsifaki, Korakaki, Karanasios, & Whiteley, 2021). 2.3. Survey distribution To our best knowledge, no study has yet assessed the current clinical practice of Swiss physiotherapists treating patients with ACLR. As the There is no official register of physiotherapists in Switzerland, hence healthcare and education systems differ from the countries mentioned physiotherapists were contacted via the Swiss Sports Physiotherapy above, it is necessary to form a better overview of how ACLR patients are Association (SSPA), the regional associations of Physioswiss (Swiss treated and how the existing recommendations are applied in Physiotherapy Association), and the different physiotherapy schools (to Switzerland, in order to understand which areas require improvement to contact alumni). The SSPA, 11 of 16 regional associations and four of achieve successful ACLR rehabilitation. seven schools agreed to distribute the survey to their members. The The aims of this study were: (1) to investigate current clinical survey was administered using REDCap (Research Electronic Data practice of physiotherapists in Switzerland when treating patients with Capture) hosted at the University of Applied Sciences and Arts Western ACLR (pre-operative and post-operative treatment, and progression (Switzerland). A recruitment e-mail was written in the three languages, until RTS); (2) to assess optimisation strategies in clinical practice, and to encourage all Swiss physiotherapists treating ACLR patients to com­ the barriers to these optimisations; (3) to evaluate if there is a relevant plete the survey. The e-mail contained a link to the survey, a brief difference (i.e. whether they are more likely to follow the recommen­ description of the study and emphasised participation anonymity. Prior dations from the literature) in clinical practice between physiotherapists to accessing the questionnaire, positive answers to the inclusion criteria with post-graduate certification in sports physiotherapy (MSc, MAS, and informed consent were requested. Data collection lasted from 3 DAS, CAS) or in-depth clinical experience treating ACLR (based on the December 2021 to 14 January 2022. number of years of experience, or the number of patients treated per year) compared with those with a BSc. It was hypothesized that: (1) 2.4. Data analysis there is wide variability in rehabilitation practice among physiothera­ pists in Switzerland regarding criteria and objective assessments during The data collected in each language were exported from REDCap to rehabilitation and RTS; (2) only a minority of patients are treated during Microsoft Excel and merged. The data were then cleaned and analysed a pre-operative rehabilitation phase; (3) only a minority of physiother­ using RStudio 2021.09.2. The participants’ characteristics were re­ apists use PROMs during rehabilitation or to assess psychological ported as frequencies and percentages. The mean and standard devia­ readiness before RTS; (4) there is wide variability of barriers to opti­ tion, or median and interquartile range were used, as appropriate. misation strategies, including constraints in infrastructure, interdisci­ Responses to the open-ended questions were analysed using content plinary communication, economics, and time; (5) physiotherapists with analysis (Graneheim & Lundman, 2004). Each response (meaning unit) post-graduate certification in sports are more likely to use objective was summarized as a condensed meaning unit. Codes were then created testing, RTS criteria, or rehabilitation duration, but independently of in- to group the similar condensed meaning units. Finally, data were im­ depth clinical experience. ported and analysed using RStudio, and reported as frequencies and 39 M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 percentages. 3.3. Post-operative phase Subgroup analysis using a chi-square test of independence was per­ formed to determine if there was a relationship between post-graduate Most physiotherapists reported seeing patients for the first time post- certification in sports physiotherapy or in-depth clinical experience operatively after 4–7 days (n = 169, 68%). The most important results and objective testing, RTS criteria or rehabilitation duration. Signifi­ for the post-operative phase are shown in Table 3. cance level was set at p < 0.05. Objective testing was set as the criteria The most reported reasons for avoiding open kinetic chain (OKC) for return to running (RTR) and using PROMs during rehabilitation. RTS exercise were stress on the ACL and lack of functionality. The most used criteria were set based on the consideration of criteria importance for criteria for RTR activities were quality of neuromuscular control (n = RTS. 230, 93.1%), pain (n = 185, 74.9%) and quadriceps strength (n = 183, 74.1%). Detailed results for the post-operative phase are available in the 3. Results Supplementary Material. 3.1. Participants’ characteristics 3.4. Return to sport From a total of 331 responders, 247 were included in the study and The most important results for return to sport are shown in Table 4. 84 were excluded due to incomplete questionnaires. Participants’ Among physiotherapists who considered sport-specific tests to be characteristics are shown in Table 1. important criteria for RTS (n = 147), 89 (60.5%) did not perform them, 30 (20.4%) reported assessing sport-specific gestures/demands, and 7 3.2. Pre-operative phase (4.8%) used on-field testing. The ACL-RSI was the currently most used psychological test (n = 76, 78.4%). Quadriceps strength was mainly The most important results for the pre-operative phase are shown in assessed with legpress (n = 127, 62.6%), squat test (n = 88, 43.3%), and Table 2. knee extension seated test (n = 74, 36.5%), while hamstring strength Among those who treated patients pre-operatively (n = 228, 92%), was assessed with seated leg curl (n = 88, 46.3%), Nordic Hamstring the mean treatment frequency was 1.82 (±0.74) per week, with a me­ Exercise (n = 72, 37.9%) and isokinetic test performed elsewhere (n = dian of 2.00 (IQR: 1.00, 2.00). The mean treatment duration was 7.27 64, 33.7%). Detailed results for current tools used for strength tests and (±6.47) weeks, with a median of 6.00 (IQR: 4.00, 8.00). Detailed results RTS are given in the Supplementary Material. for the pre-operative phase are given in the Supplementary Material. Table 1 Participants’ characteristics. French (N ¼ 78) German (N ¼ 161) Italian (N ¼ 8) Total (N ¼ 247) Age (years) Mean (SD) 34.1 (9.1) 37.2 (9.8) 38.9 (12.2) 36.3 (9.8) Median (IQR) 31.0 (28.0, 39.0) 34.0 (29.0, 43.0) 35.5 (28.7, 46.0) 33.0 (29.0, 42.0) Sex (N (%)) Female 34 (43.6%) 104 (65.0%) 5 (62.5%) 143 (58.1%) Male 44 (56.4%) 56 (35.0%) 3 (37.5%) 103 (41.9%) N-Miss 0 1 0 1 Post-graduate certification in sports physiotherapy (N (%)) No 53 (67.9%) 81 (50.3%) 6 (75.0%) 140 (56.7%) Yes 25 (32.1%) 80 (49.7%) 2 (25.0%) 107 (43.3%) Type of post-graduate certification in sports physiotherapy (N (%)) MSc 5 (20.0%) 19 (23.8%) 0 (0.0%) 24 (22.4%) MAS 0 (0.0%) 9 (11.2%) 0 (0.0%) 9 (8.4%) DAS 4 (16.0%) 10 (12.5%) 0 (0.0%) 14 (13.1%) CAS 7 (28.0%) 15 (18.8%) 0 (0.0%) 22 (20.6%) Other shorter courses 9 (36.0%) 27 (33.8%) 2 (100.0%) 38 (35.5%) Number of years treating ACLR patients Mean (SD) 7.9 (8.1) 11.5 (9.2) 13.3 (13.1) 10.5 (9.2) Median (IQR) 5.0 (2.0, 10.0) 8.0 (5.0, 15.0) 6.5 (3.0, 22.3) 6.0 (4.0, 15.0) Number of ACLR patients per year Mean (SD) 10.7 (10.1) 11.5 (19.1) 5.0 (4.0) 10.9 (16.5) Median (IQR) 7.0 (4.0, 10.0) 6.0 (4.0, 10.0) 3.5 (2.0, 6.0) 6.0 (4.0, 10.0) N-Miss 1 0 0 1 SD: standard deviation; IQR: interquartile range; N: number of participants; N-Miss: number of missing data; MSc: Master of Science; MAS: Master of Advanced Studies; DAS: Diploma of Advanced Studies; CAS: Certificate of Advanced Studies; ACLR: anterior cruciate ligament reconstruction. 40 M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 Table 2 Responses to the pre-operative phase section of the survey. Importance of pre-operative rehabilitation (N ¼ 247) Not important n= 0 (0%) Rather unimportant n= 9 (4%) Rather important n= 110 (45%) Very important n= 128 (52%) Proportion of patients already treated pre-operatively? (N ¼ 247) 0% n= 19 (8%) 1-20% n= 102 (41%) 21-40% n= 55 (22%) 41-60% n= 40 (16%) 61-80% n= 23 (9%) 81-100% n= 8 (3%) Objectives of pre-operative treatment phase? (N ¼ 228) Strengthening of the quadriceps n= 187 (82%) Resorption of post-traumatic oedema n= 184 (80.7%) Psychological preparation of the patient for the surgery and post-operative rehabilitation n= 181 (79.4%) Improvement of neuromuscular control n= 181 (79.4%) Strengthening of the hamstring n= 171 (75%) Improvement of mobility in extension n= 170 (74.6%) Patient education: walking with crutches, first post-operative exercises n= 161 (70.6%) Improvement of mobility in flexion n= 113 (49.6%) Other(s) n= 10 (4.4%) N: number of participants; n: number of responses. 3.5. Re-injury prevention frequently used interventions. The most reported reason why no re- injury prevention was implemented was lack of knowledge (n = 17, Strategies for re-injury prevention implementation were judged as 25.4%). Detailed results for re-injury prevention are given in the Sup­ important by 224 (91%) participants, and 158 (64%) reported imple­ plementary Material. menting them. FIFA11+ (n = 77, 48.7%) and individualised programs (n = 59, 37.3%) emerging from “other” responses were the most Table 3 Responses to the post-operative phase section of the survey. Duration of rehabilitation (in months) (N ¼ 247) Mean (SD) 10.58 (11.88) Median (IQR) 9.00 (6.00, 10.00) Number of physiotherapy treatments during rehabilitation (N ¼ 247) Mean (SD) 47.61 (24.67) Median (IQR) 40.00 (36.00, 55.50) Use of Open Kinetic Chain (OKC) quadriceps exercise during rehabilitation (N ¼ 247) Yes n = 225 (91%) No n = 22 (9%) Average number of post-operative weeks to begin with OKC (N ¼ 225) N-Miss 19 Mean (SD) 9.74 (6.51) Median (IQR) 8.00 (6.00, 12.00) Use of Patient-Reported Outcome Measures during rehabilitation (N ¼ 247) Yes n = 92 (37%) No n = 155 (63%) Patient-Reported Outcome Measures currently used during rehabilitation (N ¼ 92) ACL− RSI: Anterior Cruciate Ligament− Return to Sport after Injury n= 67 (72.8%) KOOS: Knee Injury and Osteoarthritis Outcome Score n= 45 (48.9%) IKDC: International Knee Documentation Committee n= 23 (25%) TSK or TSK− 11: Tampa Scale for Kinesophobia n= 14 (15.2%) K− SES: Knee Self− Efficacy Scale n= 1 (1.1%) Other n= 8 (8.7%) SD: standard deviation; IQR: interquartile range; N: number of participants; n: number of responses; N-Miss: number of missing data. 41 M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 Table 4 Responses to the return to sport section of the survey. Criteria considered as important for return to sport (N ¼ 247) Hop test(s) n= 225 (91.1%) Strength test(s) n= 209 (84.6%) Time, number of months post− operative n= 155 (62.8%) Sport specific test(s) n= 147 (59.5%) Balance test(s) n= 137 (55.5%) Agility test(s) n= 115 (46.6%) Psychological test(s) n= 97 (39.3%) Other n= 6 (2.4%) I do not consider any criteria n= 1 (0.4%) Hop tests currently used for return to sport (N ¼ 225) Single Hop Test for Distance n= 184 (81.8%) Side Hop Test n= 161 (71.6%) Triple Hop Test for Distance n= 156 (69.3%) Cross− over Hop Test for Distance n= 108 (48%) Single Limb Vertical Hop n= 56 (24.9%) 6m Timed Hop Test n= 39 (17.3%) Other n= 24 (10.7%) Muscles currently assessed with a strength test for return to sport (N ¼ 209) Quadriceps n = 203 (97.1%) Hamstring n = 190 (90.9%) Other n = 57 (27.3%) Time, number of post-operative months to allow return to sport (N ¼ 155) N-Miss 1 Mean (SD) 9.21 (4.15) Median (IQR) 9.00 (7.62, 9.88) Balance tests currently used for return to sport (N ¼ 137) Y-Balance Test n = 110 (80.3%) SEBT: Star Excursion Balance Test n = 39 (28.5%) Other n = 8 (5.8%) SD: standard deviation; IQR: interquartile range; N: number of participants; n: number of responses; N-Miss: number of missing data. 3.6. Optimisation strategies and barriers There was no significant difference in rehabilitation duration be­ tween physiotherapists with and without post-graduate certification in Physiotherapists judged their mean overall treatment quality as 6.2 sports physiotherapy (p = 0.270), or in terms of the number of ACLR on a 10-point scale. Overall, 215 (87%) physiotherapists reported a need patients treated per year (p = 0.346) (Tables 5 and 6). Conversely, for changes in their current clinical practice, and 166 (67.2%) felt having less experience was associated with significance difference (p < limited in their current treatment practice of ACLR. Responses to the 0.001) (Table 7); physiotherapists with less than six years of experience changes needed to improve rehabilitation quality are shown in Fig. 1 tended to provide longer rehabilitation (Table 7). and the limiting factors in current practice are shown in Fig. 2. 4. Discussion 3.7. Subgroup analysis The overall aim of this study was to investigate the current clinical practice of physiotherapists in Switzerland when treating patients with Physiotherapists with post-graduate certification in sports physio­ ACLR. A wide variability in practices was identified. One of the main therapy, compared with those without such certification, were more findings was that only a minority of patients are treated pre-operatively, likely to use PROMs (p = 0.007), the Y-Balance test for RTR (p = 0.006), even though the literature tends to support pre-operative rehabilitation and to consider agility tests as important criteria for RTS (p = 0.009) (Grindem et al., 2015). Indeed, pre-operative restricted knee mobility (Table 5). Physiotherapists treating more than six ACLR patients per appears to complicate post-operative rehabilitation (Quelard et al., year, compared with those treating fewer than six per year, were more 2010), and patients with a pre-operative quadriceps strength deficit of likely to consider the strength tests as important criteria for RTS (p = more than 20% still have a deficit and poorer functional scores two years 0.013) and to use PROMs (p = 0.004), whereas physiotherapists treating later (Eitzen, Holm, & Risberg, 2009). Furthermore, the main issues fewer patients were more likely to include time as a criterion for RTR (p requiring change highlighted by this study concern the lack of = 0.020) (Table 6). Physiotherapists with less than six years of experi­ criteria-based rehabilitation, which the literature recommends, and ence, compared with those with more than six years of experience, were challenges in the implementation of pre-operative physiotherapy. We more likely to consider strength (p < 0.001) and psychological (p < hypothesize that non-referral is probably one of the major reasons why 0.001) tests as important criteria for RTS, use PROMs (p = 0.004), and patients are often not treated pre-operatively, as a medical prescription assess knee mobility (p = 0.002), and effusion (p = 0.005) for RTR, is necessary in Switzerland to receive reimbursement for treatment. whereas physiotherapists with more experience were more likely to Further analysis revealed consistent practices regarding treatments, consider sport-specific tests as important criteria for RTS (p = 0.002) as most physiotherapists used OKC quadriceps exercises. Overall, 91% (Table 7). 42 M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 Fig. 1. Responses regarding changes needed to improve the quality of ACLR rehabilitation. Fig. 2. Responses regarding limiting factors in current practice. reported using OKC exercise during rehabilitation; a rate much higher elongation than closed kinetic chain (CKC) (Belloir et al., 2020; Glass, than reported in similar studies in Greece (64.3%) and Belgium (38.3%) Waddell, & Hoogenboom, 2010; Morrissey et al., 2000). As quadriceps (Dingenen et al., 2021; Korakakis et al., 2021). The use of OKC is safe strength is strongly associated with patient function (Chaput et al., when integrated progressively (Noehren & Snyder-Mackler, 2020; Wilk, 2021), and important deficits are still present many months Arrigo, Bagwell, & Finck, 2021), without leading to more graft post-operatively (Lepley, 2015) and even after two years or more 43 M. Pulver et al. Physical Therapy in Sport 65 (2024) 38–48 Table 5 Subgroup analysis: influence of having post-graduate certification on objective testing, rehabilitation duration and consideration of important criteria for return to sport. Objective testing (criteria used for return to running and use of PROMs) Criteria Post-graduate NO (N ¼ 140) Post-graduate YES (N ¼ 107) Total (N ¼ 247) p-value Knee ROM Flexion & Extension 86 (61.4%) 63 (58.9%) 149 (60.3%) 0.685 Pain 104 (74.3%) 81 (75.7%) 185 (74.9%) 0.799 Effusion 80 (57.1%) 68 (63.6%) 148 (59.9%) 0.308 Quadriceps Strength 104 (74.3%) 79 (73.8%) 183 (74.1%) 0.936 Hamstring Strength 82 (58.6%) 64 (59.8%) 146 (59.1%) 0.844 Hop tests 73 (52.1%) 58 (54.2%) 131 (53.0%) 0.748 Time, number of post-operative months 77 (55.0%) 56 (52.3%) 133 (53.8%) 0.677 Quality of neuromuscular control (stabilisation) 130 (92.9%) 100 (93.5%) 230 (93.1%) 0.853 SEBT: Star Excursion Balance Test 17 (12.1%) 17 (15.9%) 34 (13.8%) 0.397 Y-Balance Test 54 (38.6%) 60 (56.1%) 114 (46.2%) 0.006 Use of PROMs 42 (30.0%) 50 (46.7%) 92 (37.2%) 0.007 Rehabilitation duration Post-operative rehabilitation duration (months) Post-graduate Post-graduate Total (N ¼ 247) p-value NO (N ¼ 140) YES (N ¼ 107)