ObjectiveTo describe the criteria used to clear athletes to return to sport (RTS) following primary ACL reconstruction.DesignScoping review.Data sourcesMEDLINE, Embase, CINAHL and SPORTDiscus electronic databases were searched using keywords related to ACL and RTS.Eligibility criteriaProspective or retrospective studies reporting at least one RTS criterion for athletes who had primary ACL reconstruction with an autograft.ResultsIn total, 209 studies fulfilled the inclusion criteria. RTS criteria were categorised into six domains: time, strength, hop testing, clinical examination, patient-report and performance-based criteria. From the 209 included studies, time was used in 178 studies (85%), and in 88 studies (42%) was the sole RTS criterion. Strength tests were reported in 86 studies (41%). Sixteen different hop tests were used in 31 studies (15%). Clinical examination was used in 54 studies (26%), patient report in 26 studies (12%) and performance-based criteria in 41 studies (20%).SummaryTime and impairment-based measures dominated RTS criteria, despite sport being a complex physical and biopsychosocial activity with demands across all aspects of function. Time was included as a criterion in 85% of studies, and over 80% of studies allowed RTS before 9 months. Whether RTS tests are valid—do they predict successful RTS?—is largely unknown.

Objective This study estimates the impact of a statewide centralized emergency department telepsychiatry service provided in non-psychiatric emergency departments on use of mental health services. Methods Individuals treated via telepsychiatry were compared to a matched sample of individuals with mental health diagnoses who were treated in non-participating hospitals. Bivariate and two part and generalized linear regression models were used to assess differences in outpatient follow up, admission following the emergency department visit, length of stay, inpatient and total costs between the two groups. Results Between March 2009 and June 2013 there were 9,066 patients with at least one telepsychiatry visit. Of these, 7,261 had index telepsychiatry visits which we were able to successfully match. The telepsychiatry group was more likely to receive 30 day outpatient follow up than the matched controls (46% versus 16%, p,.001) and more likely to receive 90 day outpatient follow up (54% versus 20%, p<.001). Those receiving telepsychiatry were less likely to be admitted to the hospital at the index emergency department visit than the control group (11% versus 22%). The combined effect of having a telepsychiatry consult during the index emergency department visit was a 0.86 day reduction in inpatient length of stay associated with receiving telepsychiatry care. 30-day inpatient costs were $2,336 (p=0.04) lower for the telepsychiatry group. 30-day total health care costs were not statistically different. Conclusions Telepsychiatry delivered in the emergency department through a centralized coordinated program has great promise for improving linkage with outpatient mental health services while reducing inpatient utilization and hospital costs.

Background: Graft tears and contralateral anterior cruciate ligament (ACL) tears are common in pediatric athletes after ACL reconstruction. Use of objective return-to-sports (RTS) criteria, in particular physical performance tests (PPTs), is believed to reduce the incidence of secondary injury; however, pediatric norms for these tests are unknown. Purpose: To establish a proof of concept for the creation of age- and sex-based norms for commonly used RTS PPTs in healthy pediatric athletes, allowing the creation of growth curves for clinical referencing. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 100 healthy people who were between the ages of 6 and 18 years and involved in organized sports were enrolled, with even distributions of age and sex. All participants underwent 9 common RTS PPTs: stork test, stork test on Bosu, single-leg squat, single-leg squat on Bosu, clockwise and counterclockwise quadrant hops, single-leg hop for distance, 6-m timed hop, and triple crossover hop for distance. Mean performance across limbs was calculated for each individual. Chronological age, height, weight, sex, and self-reported Pubertal Maturational Observational Scale (PMOS) score were recorded. Univariable and multivariable models were created for each PPT, assessing the importance of the recorded descriptive variables. Quantile regression was used to create growth curves for each PPT. Results: The cohort was 52% female, and the mean ± standard deviation age was 11.7 ± 3.6 years. PMOS was highly correlated with age ( r = 0.86) and was excluded from the regressions. In univariable regression, age, height, and weight were strong predictors of performance for all PPTs, whereas sex was a predictor of performance on the single-leg and triple crossover hops for distance (with males outperforming females). Height and weight were excluded from multivariable regression because of multicollinearity with age. Multivariable regression showed predictive patterns for age and sex that were identical to those shown in the univariable analysis. Given ceiling effects, quantile regression for the stork tests was not possible, but quantile regression growth curves were successfully created for the 7 remaining PPTs. Conclusion: Chronological age and sex accurately predicted performance on common RTS PPTs in pediatric patients. The growth curves presented herein could assist clinicians with benchmarking pediatric patients postoperatively against a healthy athletic cohort.

Background: Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction in children is associated with a much higher risk (∼30%) of subsequent ACL injury than in adults. Most RTS testing protocols use a limb symmetry index (LSI) ≥90% on physical performance tests (PPTs) to assess an athlete’s readiness for sport. This assumes that, in a healthy state, the physical performances across both lower extremities are and should be equal. Purpose: To determine the prevalence of limb asymmetries >10% in the uninjured pediatric population on common PPTs as well as to explore the relationship between athlete variables, limb preference, and LSI values. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study included healthy volunteers (N = 100) evenly distributed between the ages of 6 and 18 years (mean age, 11.7 ± 3.6 years; 52% female). Participants performed 9 common PPTs. For analysis, we developed a composite score for each limb by averaging trials. We then calculated the LSI for each test. Univariable and multivariable linear regression analyses were performed to assess the relationship between athlete variables (age, sex, height, and weight) and LSI for each PPT. Results: Instances of poor baseline limb symmetry (<90% LSI) were common across all PPTs. The single-leg timed hop had the highest percentage of participants, with LSI ≥90% at 73%, while the stork on a Bosu ball had the lowest percentage at 23%. After adjusting for age, female sex showed a significant association with LSI for the stork test ( P = .010) and the quadrant hop–counterclockwise ( P = .021). Additionally, after adjusting for sex, increasing age showed a significant association with LSI for the stork test ( P < .001), single-leg squat on a Bosu ball ( P = .010), quadrant hop–clockwise ( P = .016), and quadrant hop–counterclockwise ( P = .009). Conclusion: The majority of healthy athletes 18 years and younger demonstrated significant (<90%) limb asymmetries. Limb symmetry was not consistently affected by participant age or sex, and the effect sizes of these relationships were small. These findings should encourage clinicians and coaches to exercise caution in using the LSI as an isolated measure of RTS readiness after injury in pediatric athletes.