After an anterior cruciate ligament (ACL) injury, people need secondary prevention strategies to identify osteoarthritis at its earliest stages so that interventions can be implemented to halt or slow the progression toward its long-term burden. The Osteoarthritis Action Alliance formed an interdisciplinary Secondary Prevention Task Group to develop a consensus on recommendations to provide clinicians with secondary prevention strategies that are intended to reduce the risk of osteoarthritis after a person has an ACL injury. The group achieved consensus on 15 out of 16 recommendations that address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. We hope this statement raises awareness among clinicians and researchers on the importance of taking steps to mitigate the risk of osteoarthritis after an ACL injury.
Knee injuries are common and account for more than 625 000 emergency department visits each year in the United States.1 The incidence increased >20% between 2002 and 2014.2,3 Many knee injuries occurred in young, physically active people; more than 1 in 3 anterior cruciate ligament (ACL) reconstructions (ACLRs) were performed in high school or college athletes in the United States.4–6 Reconstruction of the ACL often led to positive outcomes, such as a return to physical activity (eg, sport, occupational, recreational). Unfortunately, for at least 1 in 3 young patients, the knee injury was a catalyst to living with knee osteoarthritis for most of their lives. Many younger adults with knee osteoarthritis experienced reductions in quality of life, physical activity levels, and physical function—all of which may have led to long-term psychosocial and psychological concerns (eg, depression), economic challenges (eg, high medical costs), and comorbidities (eg, cardiovascular disease).7–10
Chronic knee symptoms indicative of early-onset knee osteoarthritis were present in a number of patients within a few years after an ACL injury.11–15 Various early (preradiographic) osteoarthritis criteria were met by 28% to 54% of adolescents or young adults based on their self-reported knee symptoms 6 months after an ACLR.11 Furthermore, 1 to 3 years after ACLR, 36% of people perceived their knee symptoms as unacceptable, including 10% to 13% who believed their treatment failed,12,13 and 28% who were dissatisfied with their knee.14 Between 2 and 6 years after ACLR, 40% of people reported symptoms that may have led to medical care, and 12% described a clinically relevant increase in knee pain during these 4 years.15 Up to 37% of patients underwent a subsequent knee surgery within 5 years after an ACLR,15,16 which elevated the risk of negative outcomes (eg, greater knee symptoms).16 Finally, after an ACL injury, regardless of reconstruction, 1 in 3 people had radiographic knee osteoarthritis (ie, presence of a definite osteophyte) within 10 years,17–19 creating “young people with old knees.” In the United States, the economic burden of individuals with a history of ACLR was greater than $7.6 billion per year.7
Prevention of the long-term burden of knee osteoarthritis among people after an ACL injury is urgently needed. In addition to optimizing short-term outcomes (eg, return to activity), a focus on secondary prevention of osteoarthritis can help preserve quality of life and wellness for the remainder of the patients' lives. The goal of secondary prevention is to identify an injury, illness, or disease at its earliest stages so that interventions can be implemented to halt or slow its progression toward long-term problems. The current literature on secondary prevention for people with an ACL injury lacks high-quality evidence. In the absence of consistent, evidence-based conclusions from the literature, consensus guidelines can be established by leveraging expert opinion and clinician experience.20 Consensus statements fill a unique role in emerging fields with insufficient evidence to inform clinical practice guidelines.21
Our goal was to provide clinicians with secondary prevention recommendations that were intended to (1) reduce the risk of osteoarthritis after a person has an ACL injury and (2) provide insight into areas that needed additional research. These recommendations, which were based on the available evidence and expertise from an interdisciplinary panel, encompassed a broad approach to mitigate the risk of osteoarthritis from the time of injury until the diagnosis of osteoarthritis, when osteoarthritis treatment guidelines should be consulted.22–24 We acknowledged the dearth of high-quality evidence (eg, randomized trials) to inform these recommendations. Therefore, we included all dissenting opinions from members of our task force to facilitate future discussion. Furthermore, we envisioned that this document will need to be revised in 5 to 10 years to reassess the recommendations based on emerging evidence.
SUMMARY AND RECOMMENDATIONS
The task group developed 16 preliminary recommendations (Table) to address the areas of patient resources and education, comprehensive rehabilitation programs for safe return to sport, psychological skills training, regular physical activity participation, standardized physical testing, patient support programs, and ethically sound use of technology to support recovery. Except for the cognitive-behavioral counseling recommendation (77% support), all recommendations achieved a consensus, with >80% of voters supporting each recommendation. We ordered the recommendations in part based on the timing of when the recommendations could be implemented for each patient. However, the last 4 recommendations with a consensus are overarching recommendations (eg, social support, use of technology, and coordinated care programs) that could help implement the preceding recommendations.
These consensus-based recommendations provide clinicians with secondary prevention strategies intended to reduce the risk of osteoarthritis in patients after an ACL injury. The recommendations describe a comprehensive approach to addressing a patient's physical and mental well-being after an ACL injury. We hope these recommendations foster more discussion on how we can help ensure the long-term wellness of people after joint injury, not just after ACL injury, and spark discussion about what patients need to know to be “informed consumers” in a health care system. This consensus statement can also guide research because each recommendation requires high-quality evidence to justify and refine the advice derived from expert opinion and clinician experience. We also hope this document and the accompanying evidence review raise awareness among clinicians and researchers and encourage them to take steps to mitigate the risk of osteoarthritis after an ACL injury.
This publication was supported by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) as part of a financial assistance award (Award No. 1 NU58 DP006980-01) totaling $461 914, with 65% funded by CDC/HHS and $250 000 and 35% funded by nongovernment source(s). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS, or the US government.
Jeffrey Driban, PhD, ATC, CSCS, is currently funded by the National Institutes of Health and the US Food and Drug Administration, receives fees for consulting from Pfizer Inc and Eli Lilly and Company, and is a member and former chair of the Osteoarthritis Action Alliance Steering Committee. Heather K. Vincent, PhD; Yvonne M. Golightly, PT, MS, PhD; Ali Mobasheri, BSc, MSc, DPhil (Oxon); Connie B. Newman, MD; and Daniel Pinto, PT, PhD, are members of the Osteoarthritis Action Alliance Steering Committee. Shelby Baez, PhD, ATC; Laura C. Schmitt, PT, MPT, PhD; and Lynn Snyder-Mackler, PT, ATC, ScD, are currently funded by the National Institutes of Health. Bruce Cohen, PhD, CSCS, is the owner of Excusercise. Yvonne M. Golightly, PT, MS, PhD, is currently funded by the US CDC, National Institutes of Health, and Association of Schools of Public Health/CDC; receives fees for participation in a data safety monitoring board from the National Institutes of Health; is a board member of both the Arthritis Care & Research Editorial Board and Osteoarthritis and Cartilage Editorial Board; and consults for the US Bone and Joint Initiative. Christopher M. Kuenze, PhD, ATC, is currently funded by grants from Nike, Inc. Ali Mobasheri, BSc, MSc, DPhil (Oxon), is a board member and president of the Osteoarthritis Research Society International and consults for Novartis AG, Kolon Tissue Gene, and GSK Consumer Healthcare. Connie B. Newman, MD, is a member of the Osteoarthritis Action Alliance Weight Management Task Group. Elizabeth Wellsandt, PT, DPT, PhD, is currently funded by the National Institutes of Health (Award No. R21AR075254), Rheumatology Research Foundation (Investigator Award), Nebraska Foundation for Physical Therapy (George Blanton Grant), and the University of Nebraska (Collaborative Initiative Seed Grant); has pending funding from the National Institutes of Health (Director's New Innovator Award and Great Plains Institutional Development Award–Clinical and Translational Research Scholars Program) for her work in ACL injury; and provides continuing education on ACL injury through Forward Movement and South Coast Seminars. The other authors report no conflicts of interest related to this work.