Neighborhoods and Knees: The Influence of Determinants of Health on Anterior Cruciate Ligament Reconstruction Outcomes and Risk of ReInjury

The ACLR recovery process entails tracking of progress through rehabilitation using return to sport (RTS) assessments to understand performance and patient-reported perceptions of recovery. In addition, RTS status and re-injury occurrence are used as measures of success following ACLR. Individuals navigate the lengthy recovery process while also experiencing personal, environmental, and neighborhood-level factors termed social determinants of health (SDoH) following anterior cruciate ligament reconstruction (ACLR). SDoH are neighborhood factors that affect access to and utilization of health care and are associated with a variety of health-related outcomes in children, adolescents, and adults. SDoH can be quantified using the Area Deprivation Index (ADI) or Childhood Opportunity Index (COI 3.0) which encompass 17 and 44 neighborhood-level SDoH factors, respectively.

External environmental factors, such as climate and RTS assessment facilities, may also contribute to an individual’s access to and use of post-ACLR rehabilitative care, and thus physical and psychological recovery. External environmental factors have been associated health factors such as physical activity participation and patient perceptions of care. The influence SDoH and external environmental factors on the ACLR RTS and long-term outcomes has yet to be explored.

In these studies, we leveraged data from a collaborative work group focused on ACLR recovery metrics – the ACL Reconstruction Rehabilitation Workgroup (ARROW) – which includes over 4,000 unique participants with RTS assessments, SDoH measures, external environmental, and long-term outcomes. In manuscript we found an association between neighborhood deprivation, measured by the ADI, and patient-reported, extension strength, and functional outcomes. Further, we found that neighborhood opportunity, as measured by the COI 3.0, is related patient-reported function and knee symptoms and extension strength symmetry in adolescent individuals after ACLR. Manuscript 2 was focused on the relationship between SDoH and long-term outcomes in individual’s post-primary, unilateral ACLR. We found a significant relationship between ADI and RTS status, but no significant relationships existed between ADI and second ACL injury nor COI 3.0 and RTS status and second ACL injury. The focus on manuscript 3 was to understand the association between external environmental factors including climate and site characteristics, such as average federal funding, type of institution, and RTS testing environment and RTS strength, functional, and patient-reported outcomes in individuals during early, intermediate, and late stages of ACLR recovery. We found that RTS strength outcomes were associated with climate – average monthly temperature and precipitation – but not season. Additionally, average federal funding received by the institution, type of institution, and RTS testing environment were associated with RTS strength symmetry, functional symmetry, and patient-reported outcomes in individuals post-primary, unilateral ACLR.

Each individual has unique experiences that are shaped by their surroundings including people, neighborhood, and external environment. These unique neighborhood characteristics influence the experiences adolescents and adults have following ACLR and throughout the ACLR recovery process. Understanding the effect of SDoH and external environmental factors on RTS performance and long-term ACLR outcomes will provide a broader context of the personal, neighborhood, and environmental factors impacting patient progress following ACLR, success with RTS, and risk of second ACL injury. Including SDoH into clinical practice and understanding their influence on ACLR outcomes will provide clinicians with more patient-centered care than previously known in this population, and ultimately improve clinical care, clinical decision making, and quality of life for their patients.