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Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus
  1. Stephanie Rose Filbay1,
  2. Søren T Skou2,3,
  3. Garrett S Bullock4,
  4. Christina Y Le5,6,
  5. Anu M Räisänen7,8,
  6. Clodagh Toomey8,9,
  7. Allison M Ezzat10,11,
  8. Alix Hayden12,
  9. Adam G Culvenor10,
  10. Jackie L Whittaker6,11,
  11. Ewa M Roos13,
  12. Kay M Crossley10,
  13. Carsten Bogh Juhl13,14,
  14. Carolyn Emery15
  1. 1 Department of Physiotherapy, University of Melbourne, Melbourne, Victoria, Australia
  2. 2 Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  3. 3 Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
  4. 4 Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  5. 5 Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
  6. 6 Arthritis Research Canada, Richmond, British Columbia, Canada
  7. 7 Department of Physical Therapy Education, Oregon, Western University of Health Sciences College of Health Sciences, Northwest, Lebanon, Oregon, USA
  8. 8 Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  9. 9 School of Allied Health, University of Limerick, Limerick, Ireland
  10. 10 La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Victoria, Australia
  11. 11 Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
  12. 12 Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
  13. 13 Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
  14. 14 Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, Denmark
  15. 15 Kinesiology, University of Calgary, Calgary, Alberta, Canada
  1. Correspondence to Stephanie Rose Filbay, Department of Physiotherapy, University of Melbourne, Melbourne, VIC 3010, Australia; stephanie.filbay{at}


Objective Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations.

Design Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed.

Data sources MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021.

Eligibility Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury.

Results Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2–14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2–5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (−1.5 (−2.9 to –0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL).

Conclusion There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

  • physical activity
  • osteoarthritis
  • rehabilitation
  • anterior cruciate ligament
  • quality of life

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  • Twitter @stephfilbay, @STSkou, @yegphysio, @amraisanen, @clo2me, @agculvenor, @jwhittak_physio, @ewa_roos, @CarolynAEmery

  • Contributors All authors conceived the study idea and designed the study; SRF, STS, GSB, CYL, AMR, CT, AME and CE contributed to screening articles and full texts, data extraction and risk of bias appraisal; KAH codesigned and ran the search; GSB and SRF analysed the data and produced figures; SRF and CBJ performed GRADE certainty of evidence assessment; SRF drafted the first version of the manuscript and subsequent revisions; all authors contributed to editing of the manuscript and approved the final version.

  • Funding This review is part of the OPTIKNEE consensus ( which has received funding from the Canadian Institutes of Health Research (OPTIKNEE principal investigator JLW #161821). SRF and AGC are supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (#1194428 and #2008523, respectively), STS is supported by a programme grant from Region Zealand (Exercise First) and two grants from the European Union’s Horizon 2020 research and innovation programme, one from the European Research Council (MOBILIZE, grant agreement No 801790) and the other under grant agreement No 945377 (ESCAPE). CYL is supported by The Arthritis Society Training Graduate PhD Salary Award (TGP-19-0400) and Canadian MSK Rehab Research Network 2017 Trainee Award (CIHR FRN: CFI-148081). CT is supported by a Health Research Board (HRB) Emerging Investigator Award (EIA-2019-008). AME is supported by the Canadian Institute for Health Research. JLW is supported by the Michael Smith Foundation for Health Research Scholar Award (SCH-2020-0403) and the Arthritis Society STAR Career Development Award (STAR-19-0493).

  • Competing interests SRF is an Associate Editor with the Journal of Science and Medicine in Sport and a board member of Osteoarthritis Research Society International (OARSI), JLW and AGC are Associate Editors of the British Journal of Sports Medicine (BJSM). JLW is an Editor with the Journal of Orthopaedic & Sports Physical Therapy. KMC is a senior advisor of BJSM and holds a research grant from Levin Health outside the submitted work. EMR is Deputy Editor and CBJ an Associate Editor of Osteoarthritis and Cartilage. EMR and STS are cofounders of Good Life with Osteoarthritis in Denmark (GLA:D®), a not-for-profit initiative hosted at University of Southern Denmark aimed at implementing clinical guidelines for osteoarthritis in clinical practice. STS is also associate editor of the Journal of Orthopaedic & Sports Physical Therapy, has received grants from The Lundbeck Foundation and personal fees from Munksgaard, all of which are outside the submitted work. All other authors declare no competing interests.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.