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. 2025 Feb 19;13(2):23259671241300300.
doi: 10.1177/23259671241300300. eCollection 2025 Feb.

Reason Profiles for not Returning to Preinjury Activity Level Following Anterior Cruciate Ligament Reconstruction- A Latent Class Analysis With Subgroup Comparison of Patient-Reported Outcome Measures

Joseph D Lamplot  1   2 , Erich J Petushek  3   4 , Camryn B Petit  1   5 , Shayla M Warren  1   6   7 , Kim D Barber Foss  1   6   7 , Alexis B Slutsky-Ganesh  1   6   7   8 , Melanie Valencia  1 , Charles D Kenyon  6 , April L McPherson  1   6   7 , John W Xerogeanes  1   6   7 , Gregory D Myer  1   6   7   9   10   11 , Jed A Diekfuss  1   6   7
Affiliations

Reason Profiles for not Returning to Preinjury Activity Level Following Anterior Cruciate Ligament Reconstruction- A Latent Class Analysis With Subgroup Comparison of Patient-Reported Outcome Measures

Joseph D Lamplot et al. Orthop J Sports Med. .

Abstract

Background: Given the high proportion of athletes who do not return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR), strategies are needed to identify at-risk patients and optimize rehabilitation for successful RTS after ACLR.

Purpose/hypothesis: This study used latent class analysis (LCA) to characterize a unique clustering of reasons why athletes do not return to their preinjury activity level after ACLR. We hypothesized that patients with high pain scores and high levels of fear would be less likely to return to their preinjury activity level.

Study design: Cohort study; Level of evidence, 3.

Methods: All patients at a single institution who underwent primary ACLR between 2005 and 2021 were contacted to complete a survey via REDCap. Patients' ability to RTS and their preinjury activity level, reasons for inability to return to the preinjury activity level, and patient-reported outcome scores were collected from 981 patients. LCA was performed to identify and compare patterns among patients' reasons for not returning to the preinjury activity level.

Results: Of the 981 patients included, only 446 (45.5%) were fully able to return to their preinjury activity level. LCA categorized patients into 3 groups based on their reasons for not returning to preinjury activity levels: a high-function group (75.5%), which reported no barriers; a multisymptom group (16.1%), which cited pain, lack of strength, and instability; and a fear-limited group (8.4%), which reported fear as the sole reason. Among the high-function group, 86.2% reported RTS compared with <36.7% in the other classes. There was no difference in Knee injury and Osteoarthritis Outcome Score (KOOS) subscales-including Pain, Symptoms, or Activities of Daily Living-between the high-function and fear-limited groups; however, the multisymptom group presented with the lowest scores in all KOOS subscales (P < .001). In addition, patient characteristics, the time from the index ACLR to the follow-up, and subsequent revision ACLR were similar between groups; however, the multisymptom profile demonstrated the highest proportion of allograft ACLR (P = .04) and secondary ipsilateral surgery (P < .001). Overall subjective knee grade (1-100) and Marx scores were highest in the high-function group, followed by fear-limited and multisymptom groups (P < .001).

Conclusion: Patients were differentiated into 3 distinct classes after primary ACLR. Furthermore, those with patient-reported characteristics of pain, lack of strength, instability, or fear were significantly less likely to return to their preinjury activity level or sport.

Keywords: anterior cruciate ligament; kinesiophobia; knee ligaments; latent class analysis; patient-reported outcome measures; psychological readiness; return to sports.

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Conflict of interest statement

One or more of the authors has declared the following potential conflict of interest or source of funding: J.D.L. has received hospitality payments from Arthrex and Smith+Nephew and education payments from United Orthopedics, DePuy Synthes Products, Smith+Nephew, and Elite Orthopedics. J.W.X. has received a royalty or license from Arthrex; nonconsulting payments from Arthrex; consulting fees from Arthrex and Trice Medical; and education payments from United Orthopedics. G.D.M has current and ongoing reserach funding to his institution from Arthrex inc to evaluate ACL surgical treatment strategies. 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 Emory University (STUDY00003512).

Figures

Figure 1.
Figure 1.
Return to the preinjury activity level by patient class.
Figure 2.
Figure 2.
Reasons for not returning to the preinjury activity level by patient class. ROM, range of motion.
Figure 3.
Figure 3.
Typical responses to the questions used in the LCA-determined groups. ACL, anterior cruciate ligament; LCA, latent class analysis.
Figure 4.
Figure 4.
KOOS and knee grade scores by patient class. ADL, Activities of Daily Living; KOOS, Knee injury and Osteoarthritis Outcome Score; LCA, latent class analysis; Sport, Sports-specific; QoL, Quality of Life.
See this image and copyright information in PMC

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