Exploring the support environment for people following anterior cruciate ligament injury in Aotearoa New Zealand

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O'Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8370277/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Anterior Cruciate Ligament (ACL) injury and subsequent ACL reconstruction (ACLR) have a significant health impact in Aotearoa New Zealand (AoNZ). These injuries frequently lead to the development of post-traumatic osteoarthritis (PTOA) and can considerably disrupt the lives of typically young, active individuals, often requiring lengthy rehabilitation and effecting overall well-being. This study aimed to gain insights from health professionals and the communities caring for people with PTOA following ACL injury in the medium- to long-term in AoNZ to inform more effective and contextually appropriate approaches to management and well-being for this patient group. Method A qualitative Interpretive Description study was employed. Semi-structured individual interviews gained insights from end-users who could speak to the management of people with PTOA following ACL injury. Data were thematically analysed. Findings: 16 participant end-users including health professionals, sports coaches, whānau (family), and policy makers were interviewed. Four themes were developed from the data: 1) Knee for life: Supporting the whole journey (recognising the long-term consequences of PTOA that can be neglected in the health system), 2) Care beyond the clinic (community engagement and a collaborative effort is required to provide long-term holistic care), 3) The blame game (financial and hierarchical conflicts surround ACL and PTOA rehabilitation, where limited accident insurance funding, and a reluctance of external services to accept responsibility impede outcomes), and 4) Shifting the goal posts: Beyond athletes and sport (a prominence of sport and athlete models of care dominate ACL management, where care and successful outcomes should extend beyond the physical aspects and more closely reflect holistic measures and patients' personal goals). Conclusion and Impact: ACL injuries should be viewed as a lifelong evolving journey rather than self-limiting isolated events. Clinically, adopting a multidisciplinary, patient-centred approach is critical. Early and sustained patient education on long-term knee health, lifestyle adaptation, and involving whānau in rehabilitation are essential. Transitioning from an injury-focused model to a holistic, sustainable support approach can significantly enhance long-term outcomes after an ACL injury and development of PTOA. Future research should prioritise developing and evaluating integrated, context-specific care models specific to the AoNZ context. Anterior cruciate ligament Knee Management Osteoarthritis Physiotherapy Post-traumatic Rehabilitation Aotearoa New Zealand Background ACL injuries have a significant health impact in AoNZ, with a high and rising incidence that, despite surgical reconstruction (ACLR), continues to result in elevated levels of symptoms and disabilities for individuals’ years post-surgery ( 1 , 2 ). ACL injuries the lives of typically young, active individuals, often requiring lengthy rehabilitation combined with ACLR, which interferes with participation in sports, daily activities and overall well-being ( 3 ). The long-term impact of ACL injury on people in AoNZ extend well beyond the immediate trauma of ligament rupture, surgery, and rehabilitation where consequences can include changes to mood, confidence, and self-perception as well as severe impacts of loss of employment ( 3 ). One of the most serious outcomes of ACL injury is the significantly elevated risk of PTOA in the affected knee. While estimates vary, several studies suggest that approximately half of the individuals who sustain an ACL injury develop knee osteoarthritis within 10–20 years ( 4 ). These injuries typically affect young adults, meaning many people from AoNZ may have PTOA by mid-life and face a higher likelihood of requiring knee replacement than those without prior ACL injury ( 5 ). Thus, an ACL injury is not merely an acute setback but a potential catalyst for chronic joint deterioration and long-term disability ( 1 ). Importantly, rehabilitation and recovery after ACL injury and ACLR do not occur in isolation but within a socioecological context ( 6 ). AoNZ’s healthcare system offers universal no-fault injury coverage via Accident Compensation Corporation (ACC), ensuring access to healthcare and income compensation following ACL injuries. There are approximately 3,000 ACLRs annually with ACC spending around NZ $ 14,000 on the recovery of each one ( 7 , 8 ). However, significant ethnic and socioeconomic disparities in ACL injury incidence and care have been noted across communities. For example, in AoNZ, Pacific peoples (who make up 8.9% of the population( 9 )) have the highest ACL injury rates and personal factors such as access to physiotherapy, health knowledge, and motivation can significantly influence rehabilitation adherence and outcomes ( 10 , 11 ). These factors underscore that effective ACL injury management requires a holistic approach attuned to the surrounding context as multiple influences impact on a patient’s recovery journey ( 12 ). Given this complex rehabilitation environment, the perspectives of end-users are crucial for fully understanding and improving ACL injury management. Health professionals commonly provide treatment and guidance; however, patients’ experiences are supported by many other connections, such as whānau, employers, colleagues, friends, and sports coaches ( 3 ). Furthermore, broader organisations and health systems influence rehabilitation and long-term impacts, such as advocacy groups (i.e., Arthritis New Zealand), funders and policymakers (i.e., ACC, Health New Zealand, Ministry of Health), which can shape the rehabilitation environment. Our recent work has called for greater end-user involvement in designing long-term ACL injury care strategies tailored to AoNZ’s context as little is known about what different groups expect from current ACL injury and ACLR rehabilitation ( 3 ). Capturing these experiences and perspectives is vital to inform more effective, contextually appropriate approaches to ACL injury and the medium- to long-term ACLR management in AoNZ. Methods Research question and aim This qualitative research explored the question, “ What are end-user perceptions and experiences of working with people with PTOA following ACL injury in the medium- to long-term in AoNZ?” to gain insights from various end-users into the medium- and long-term impact of ACL injury, ACL injury management, and PTOA in AoNZ. Design and ethics This Interpretive Descriptive study was informed by a realist philosophical lens and followed the Consolidated Criteria for Reporting Qualitative Research ( 13 ) checklist and reporting guidelines. Interpretive Description was selected because it focuses on capturing subjective perceptions and understandings of health-related experiences and interpreting them to inform credible and meaningful clinical understanding ( 14 ). Data were analysed using Reflexive Thematic Analysis, which allows the construction of inductive and latent themes, providing valuable insights into phenomena ( 15 ). The Auckland University of Technology Ethics Committee approved this research (AUTEC #: 22/257) (Clinical trials number: not applicable). Participants and recruitment We aimed to purposively recruit 12–15 end-users who have experience with the management of PTOA following ACL injury in AoNZ. Potential participants were recruited through direct contact via publicly available emails by one of the research team and via the snowball method ( 16 ), and invited to participate in an individual interview. We aimed for diversity in ethnicity, health profession, health sector role (managerial, policy, front-line), geographical area of work, and level of involvement with ACL and PTOA patients. Participants were excluded if they could not communicate in English. Data generation Participants were encouraged to share their beliefs about ACL injury management in AoNZ, including treatment, lasting impact, and service design and delivery during 30–60-minute, face-to-face online interviews. The interviews were semi-structured to allow flexibility in exploring the participants' narratives while being guided by an interview schedule (Additional File 1) and the researchers’ expertise and personal experience with ACLR and PTOA (DOB, JT). The schedule was adjusted iteratively as the study progressed based on participants' responses, development of issues, emerging observations, and a deeper understanding of the phenomenon ( 17 ). Interviews were conducted between July and November 2023, video-recorded, and transcribed verbatim. The interviewer(s) (DOB and/or JT) wrote summary memos reflecting their thoughts after each interview, which were included in the data synthesis and theme construction. Participants had the opportunity to review the transcripts and give feedback on accuracy. Researcher Positionality and Paradigm Interviewers DOB (male) and JT (female) were from AoNZ, were experienced qualitative health researchers, and registered physiotherapists with extensive ACL injury and ACLR rehabilitation experience professionally and personally. Subthemes and themes were presented to the broader research team, who, while all physiotherapists, brought a range of experiences and viewpoints including working extensively with Māori and Pacific peoples; elite sport; ACL research; and professional and personal ACL injury, ACLR and PTOA experience. Data analysis Data were analysed using Reflexive Thematic Analysis, a flexible approach that enables a rich, detailed, and complex account of the data and allowing themes to be developed that are applicable for clinical practice ( 18 ). Data collection and analysis were carried out concurrently, allowing insights developed during earlier interviews to be checked in later interviews, presenting opportunities to refine the research and reorient the inquiry according to developing insights ( 19 ). Two researchers (DOB, JT) manually coded all transcripts. Inductive coding allowed meaning to be grounded in the data ( 18 ). Latent codes were generated following the recommendations of Terry and Hayfield ( 15 ), capturing meaningful data interpretations, followed by independent theme and subtheme development through active pattern formation and identification. The researchers returned to the raw data and initial coding recursively to ensure a deep level of interpretation and that the analysis related to the research question ( 15 ). Ongoing collaboration with the wider research team occurred before the final themes and theme names were decided. Participant quotes illustrative of constructed themes are included in the findings. Results Sixteen people with a broad range of ACL injury (acute ACL ruptures, re-ruptures and ACL surgery) and PTOA management experience (18 months to over 30 years as clinicians and support persons) participated in the study (see Table 1). Most were women and of New Zealand European ethnicity. However, two participants did identify as Māori and two with Sāmoan ethnicity. Participants were from a range of major urban centres around AoNZ: Auckland, Hawkes Bay, Wellington, and Christchurch, affiliated with organisations such as Arthritis New Zealand, ACC, Te Whatu Ora, Te Aka Whai Ora, High Performance Sport, Netball New Zealand, and Moana Pasifika, and encompassed a wide range of roles from coaching and parenting to physiotherapy, sports medicine, surgery, and organisational leadership. All participants were provided copies of their interview transcripts, with minimal amendments requested. Table 1. Participant Characteristics (n=16) Gender n (%) Women Men 9 (56) 7 (44) Ethnicity n (%) New Zealand European Māori Asian Sāmoan/ Japanese Sāmoan/ New Zealand European South African No response 9 (56) 2 (13) 1 (6) 1 (6) 1 (6) 1 (6) 1 (6) Roles n (%) Physiotherapist Parent Physician Chief Executive Officer Coach Manager Musculoskeletal Project Facilitator Organisation Co-Chair Principle Advisor Surgeon 5 (31) 2 (13) 2 (13) 1 (6) 1 (6) 1 (6) 1 (6) 1 (6) 1 (6) 1 (6) Identified Themes We constructed four themes from the data: 1) Knee for life: Supporting the whole journey, 2) Care beyond the clinic, 3) The blame game , and 4) Shifting the goal posts: Beyond athletes and sport. Knee for life: Supporting the whole journey This theme draws on participants’ perceptions that ACL injuries are arguably managed well at the time of injury yet have long-term consequences that are sometimes underemphasised or neglected by certain healthcare providers. Participants expressed concern that rehabilitation was lacking for patients outside the commonly practised ACL rehabilitation timeline of nine to twelve months post-injury, with or without surgery, which affected their long-term care. For example, one participant said, “After that period of time [initial rehab], in the New Zealand system, I'm not sold we do a lot for those patients.” (Participant 3, physiotherapist). Concerns were expressed that gaps appeared where patients prematurely lost access to medical care following their ACL surgery rehabilitation: “I think it's 12-month check-in, maybe 6 to 12 months…And really nothing else happens after that. And so, you're left on your own.” (Participant 1). Moreover, subsequent knee issues that arose after rehabilitation ended were unexpected for patients, with participants reporting that patients had difficulties managing their care at this stage: “Suddenly, a person, potentially around 30, mid-30s, is starting to have that [knee] issue. And for a lot of them, that will be an absolute bolt out of the blue.” (Participant 1). This gap in care also highlighted the lack of long-term education that patients receive. Initial education and messaging can be chaotic, overwhelming, and devoid of information about long-term ACL injury and PTOA management. “One of the things I'm not sure we do well enough, whether it be in ACLs or musculoskeletal physiotherapy full stop, is educating our patients enough about what it means here and now and what it means for the future.” (Participant 8). Conversely, participants recognised that patients also carry responsibility and often do not understand or prioritise the long-term effects of a knee injury, reporting “We don't think about our future self.” (Participant 4). Participants perceived patients desired quick solutions and were not always focused on comprehensive rehabilitation: “Quick fixes, get back on the field, what do I need to do that?” (Participant 14). Further adding to this sentiment, one participant (a physiotherapist) appeared to assume that poor patient engagement in long-term care indicated the patient had met all their rehabilitation targets: “I'm assuming they're getting back and running around doing alright.” (Participant 5). However, many participants felt that long-term care and education were necessary for these individuals. One participant (a mother) reported: “I couldn't have imagined having her just discharged from the physio and that was that. Like, I felt like we would have needed to go back on a regular basis, even if it was just every couple of months.” (Participant 12). Several participants emphasised the need for long-term care, recommending regular post-injury check-ins with screenings to address knee concerns: “And do we look at some preventative screening at certain intervals along that pathway? Yeah. That would be of benefit.” (Participant 3). Solutions were also provided as participants perceived long-term care to be enhanced and nurtured through whakawhanaungatanga (relationship building). Creating spaces of trust and partnership can empower patients to manage their knees more effectively: “You build up quite a relationship with that patient and often their whānau as well, depending how old that patient might be and therefore how involved the family are.” (Participant 3); and “So again, that therapeutic relationship. If you say to somebody towards the end of their treatment, ‘If things aren't working, come back’ is probably the biggest single thing that people would need. Is that kind of permission to come back.” (Participant 5). Care beyond the clinic This theme recognises that social support and community involvement are crucial to patient care in the short- to medium-term. Participants reported ACL injury and PTOA rehabilitation as heavily individualistic and collaboration outside immediate medical care can be overlooked “The way our system looks at it, it looks at an individual. It doesn't look at whānau.” (Participant 7). The physical health approach to ACL injury and PTOA care continued to dominate and restrict alternative views of health. “When you're part of a team, you're a piece of the puzzle. With this, I was individual. I really struggled the first time mentally. Everyone said you were going to be fine. And in the sense that you're physically going to get fine.” (Participant 16, coach). However, models that enhance social support for patients through sports teams, community organisations, and rehabilitation programmes should be explored and embraced. Participants believed that a more collective community and social approach helped health services deliver essential holistic care: “I think the social aspect of people with a chronic condition is really important. And maybe having that support would have been better on our programmes.” (Participant 1, physiotherapist). Holistic care is portrayed well by one participant, a Māori health manager and practitioner, who reported the need to look at the whole person to provide necessary healing: “So wairuatanga, the mauri, the tapu, the mana (the layers forming the essence of the person). And so, depending on which thing is impacted with the person, is where we'll interact with them to strengthen a connection and get in sync, and then help them to heal themselves.” (Participant 7). The benefit of social connections and how this approach was significantly beneficial for the patient’s journey and outcome success was frequently mentioned during the interviews, within the high-performance environment “You see the elite ones, the Mystics [provincial netball team] or New Zealand [national netball team], and you see the players in the stand or still part of the team from that perspective.” (Participant 16); and grass-roots level “Her club netball coach was amazing. Kept her involved, kept her with the team.” (Participant 12, parent); and “Telling the team that she is still part of the team, even though she's injured, ‘You need to support her, and she's still part of what we do’.” (Participant 16, coach). However, in general the social care provided by high-performance clubs did not regularly appear to transfer to the grass-roots level, with the experiences of Participant 12 and 16 being outliers and considered to be due to an individual rather than a club-wide value. Although participants perceived sports teams and clubs as influencing their players' journey and outcome, they appeared hesitant to engage with health rehabilitation: “They've got a part to support the ongoing welfare of their players. And we've seen a lot of older players who have not been supported or could have been supported better.” (Participant 1). Participants reported that families also have roles to play in providing support. One participant, a parent, spoke on the social role she provided: “My role was more about economic support. The partner was very good with emotional support”; and “The vā feagaiga (relational bond between brother and sister), they have to support her in whatever way she needs it.” (Participant 13). Ultimately, injury management cannot be placed solely on the individual, rather it is a shared role with health professionals and the wider community and essential in the short- to medium-term. The blame game The ‘blame game’ underscores the financial and hierarchical conflicts surrounding ACL injury and PTOA rehabilitation, the effects of limited ACC funding, and the reluctance of external services to accept responsibility. Funding and ACC were consistently emphasised throughout the interviews as participants firmly believed that ACC was central to ACL injury and PTOA care and barriers to funding as unjust: “I think ACC has to be roped in because ACL injuries are ACC injuries, plain and simple.” (Participant 2); and “I think cost is probably the biggest barrier for most people.” (Participant 15). Funding challenges were so unjust that to provide necessary care one participant reported risking their ethical responsibilities: “There's ten people in the way of you getting help for your knee. Whereas, if I sign an ACC form, there's no one in the way. Hence, everyone turning up, and people like myself turning a blind eye to the law and our ethics and all other things and getting them some help.” (Participant 14). There was also a common perception that ACC held tight purse strings and was ignorant to the full scope of patient care: “I get it because ACC has got to deliver on what ACC is. But that's not necessarily helping the health of our nation.” (Participant 14). Blame for inadequate patient care was also attributed to the dominant hierarchical power and influence of surgeons. Participants felt that surgeons and senior management held dated views on rehabilitation: “A lot of these surgeons feel physio is not needed. They do the knee replacement; the patient will be fine.” (Participant 2). In addition to surgeons and senior management’s absolute authority to enact these views, one participant stated: “There's no check in the system, a SMO [senior medical officer] has the power and the authority to do that, and they do that unchecked.” (Participant 7). Turf wars, where professions cling tightly to their individual areas of practice, were also perceived to be prevalent and contributing to inadequate patient care: “Orthopaedics, without sounding too controversial, is a white males club, and they are particularly patch protective. They're an arrogant group of people. Confident, arrogant, whichever way you want to put it. And they struggle enough taking referrals from physiotherapists, let alone taking referrals from people that, in their opinion, would have no health background.” (Participant 3). A delicate dance was believed to be necessary to begin addressing the power imbalances and to challenge the progressive views on rehabilitation: “I don't think we sideline them [surgeons], but we've got to get them on side. And get them to start to understand the distribution of power.” (Participant 3). With blame firmly placed on limited funding and power dynamics, the acceptance of the absence of outside services to take accountability tended to be normalised within sports systems: “I don't think Sport New Zealand will be interested because, as I say, their focus is up to 18 [years old], and they've pushed back a lot on other areas where they sort of haven't seen it their business.” (Participant 1); educational systems “Teachers are overwhelmed and can't do anything additional, [that] is their starting position.” (Participant 10); and workplaces “Because we've got a bit of a double-edged sword. We want people back at work, but employers don't want to carry risk.” (Participant 5.) Conversely, participants recognised the need for outside services to be involved, understanding that no single service should bear all the responsibility or burden including sports clubs: “I still think individual things like rugby, some of the clubs, and the sports could actively be a real participant in this whole engagement. As we talked about, how do we keep them involved in the game?” (Participant 1); and schools “Schools should be a lot more supportive of school kids when they have injuries.” (Participant 16). Participants also felt that patients needed to take accountability, to stop heavily relying on ACC, and be realistic about their own care: “This is a journey that doesn't finish once ACC stops funding you. You need to carry on being accountable yourself, for looking after yourself as well.” (Participant 8); and take personal responsibility for their own well-being, reducing reliance on overworked and underfunded health systems: “The first one ruptured her ACL the first game back after her having had 10 years away from netball. Did the quick run, a cursory stretch, and a couple of lunges for old times' sake.” (Participant 8). Shifting the goal posts: Beyond athletes and sport This theme was characterised by the prominence of sport and athlete models of care in ACL injury management, where care and successful outcomes should extend beyond the physical aspects and more closely reflect holistic measures and patients' personal goals. Participants often described the ACL injury world through a sporting lens, referring to patients as athletes: “…like a 40-year-old athlete who wants to get another season or something.” (Participant 4). Furthermore, physical health was viewed as central to patient care, in alignment with the design of health systems. Participants described rehabilitation for ACL injuries and PTOA, emphasising physical and objective measures: “How do you protect these guys for longer to push away the knee replacement? That's probably strength and range of movement work.” (Participant 4); and “We've got really good systems and structures in place to ensure that we're not returning patients prematurely to a situation they're not ready for from a physical perspective.” (Participant 15). However, participants also reported that physical goals and returning to sport were not always prioritised by patients, and they acknowledged a need to look beyond physical health and sport as the perception of outcome success. “That sort of six to nine months is the most important time, really, because that's where we get our strength up so that we can have at least 90% of the function to our opposite leg, right? And so, it's funny. That's almost, debatably, the most important part for the physio, but it's the least important part for the patient...” (Participant 6, physiotherapist). Participants also found engagement improved when outcome success was viewed from the patient's perspective, placing their goals at the centre of rehabilitation. “We can engage them until a point they get to where they wanted to get to. So, if that's back on the field, great. If it's back at work or it's back out of pain, everyone's got a different target.” (Participant 4, surgeon). Arguably, the sporting identity and platform that sport holds in ACL injury care appear to be shifting. Participants reported that sports and sporting stars are no longer viewed as the best way to advertise care, and are instead looking towards more community-focused, realistic daily activities: “I'm not sure that they are the best role models, thinking of your Michael Jones [rugby sporting star] example [laughter], are they the best models? Perhaps not.” (Participant 5); and “I’ve seen all the ‘have a hmmm’ ads, the ACC ads. And I was like, ‘Man, those are much better now.’ And I think they've won awards for them, actually. It makes sense, though, because you've got that whānau element.” (Participant 6). Discussion This study explored diverse perspectives on the medium- to long-term impacts of ACL injury and PTOA in AoNZ from a wide group of end-users. The findings indicate that an ACL injury is not just an acute event but the beginning of a “knee for life” journey, with consequences that extend well beyond initial treatment. Participants identified four interrelated themes: long-term implications of ACL injuries, a “blame game” around funding and responsibility, the influence of athletic identity on rehabilitation, and the importance of community engagement and social support. Together, these themes address our research question by highlighting that effective long-term management of ACL injuries requires attention to lifelong knee health, more transparent accountability across health and social systems, consideration of patients’ identities and goals, and stronger community and whānau support. In summary, the broader support environment for people after ACL injury in AoNZ appears fragmented and underprepared to meet the “knee for life” challenge, underscoring the need for more cohesive, patient-centred strategies. Long-term implications and continuity of care Participants described how ACL injuries often set the stage for chronic knee issues, yet medium- to long-term follow-up and education are lacking. Despite generally good acute management, participants noted a post-rehabilitation void where patients are “left on [their] own” after the typical 9 to 12-month rehabilitation period. This reflects a health system culture that prioritises immediate recovery milestones (e.g., return to sport or work), but underemphasises ongoing surveillance and secondary prevention of knee osteoarthritis. Participants lamented that patients are seldom warned about this high PTOA risk or equipped with long-term self-management strategies. This finding aligns with recent qualitative research by O’Brien et al. ( 3 ), where individuals over five years post-ACL injury reported that “nobody ever told” them about the likelihood of osteoarthritis and wished they had more guidance on long-term knee care. Holm et al. ( 20 ) also found ACL injured individuals in Denmark were not provided adequate long-term education causing mixed views on the future of their knees. Both patients and participants thus identify a critical gap in continuity of care. Providers may assume a patient is “doing all right” once formal rehabilitation ends, yet participants observed that knee problems often resurface unexpectedly later. The “Knee for Life” theme aligns with previous research which emphasises that an ACL injury should be viewed as a lifelong condition, necessitating preventive interventions, and patient education that extend well beyond the initial rehabilitation period ( 21 ). Community engagement, social support, and equity The “Care beyond the clinic” theme underscores that successful long-term adaptation to ACL injury is not solely a medical endeavour but a social one. Participants in our study stressed that early intervention from the wider community, including sports clubs, teams, schools, employers, and whānau, play a pivotal role in a person’s rehabilitation journey and well-being. However, current systems often adopt an individualistic approach, where formal rehabilitation focuses on the patient in isolation. Participants noted that community resources and social networks are underutilised; for instance, grassroots sports clubs rarely have formal programmes to keep injured players involved, despite the benefits seen by some coaches who supported injured players with team roles. This finding aligns with the literature, which indicates that social support has wide-ranging effects on recovery, influencing emotional well-being, motivation, exercise participation, and physical outcomes ( 22 , 23 ), and adequate support from family, friends, and peers can buffer psychological stress after ACL injury, while social isolation or lack of understanding can hinder rehabilitation ( 24 ). Māori and Pacific models of health emphasise holistic considerations including collectivism, relationships, and spiritual well-being. Ensuring all elements maintain balance is central to recovery or a form of homeostasis ( 25 , 26 ). As reported by participants, cultural concepts including whanaungatanga and “vā feagaiga” were considered fundamental to healing in Māori and Sāmoan worldviews, ensuring patients feel connected and fully supported in their journey. Our findings suggest that implementing Māori and Pacific principles of care could enhance the experience and outcomes for people with ACL injuries, particularly for the AoNZ environment ( 27 , 28 ). Furthermore, attention to equity is crucial. Pacific peoples in AoNZ have the highest incidence of ACL injuries and associated costs with significant ethnic and socioeconomic disparities in ACL injury outcomes ( 10 ). These inequities mean that those already underserved by the health system are at risk of worse long-term consequences. Our participants advocated moving beyond professional “turf wars” and fostering partnerships across health, sports, and community sectors. By leveraging community strengths (such as the camaraderie of a team or the caregiving roles of whānau) and embedding support within a patient’s everyday life context, the broader support environment can become more inclusive and effective in ACL injury management, long-term knee health and overall well-being. System fragmentation, funding, and accountability The “blame game” theme revealed participant frustrations with fragmentation in the support system and ambiguity in responsibility for long-term ACL injury management. Participants frequently pointed to AoNZ’s no-fault injury compensation system, ACC as essential and yet limiting. ACC provides universal coverage for acute injury care, but its funding constraints and episodic structure may leave those with chronic post-ACL issues in limbo. Many noted that once ACC-funded rehabilitation or wage compensation ends, patients can struggle to access further support, feeling abandoned by the system, a finding that resonates with broader concerns about silos and service fragmentation in injury care ( 29 ). Participants described a tendency for various end-users to operate in isolation, often assuming that someone else will take charge of the patient’s healthcare coordination and long-term well-being. Indeed, our participants saw a ‘passing of the buck’. For example, surgeons focus narrowly on surgical outcomes, while community or sports groups hesitate to assume any formal role post-rehabilitation, and physiotherapists do not consistently offer longer-term care and guidance. Such fragmentation not only frustrates providers but also exacerbates inequities in care continuity. If patients lack personal resources or knowledgeable advocates, they are less likely to navigate the gap between acute care and chronic management. Our findings underline the need for more integrated and accountable care pathways. ACC has recently introduced an Integrated Care Pathway for musculoskeletal injuries that assigns patients a dedicated team and navigator to coordinate treatment from injury through recovery ( 29 ). This model, which encompasses services beyond the initial injury episode, represents a promising step toward overcoming some funding and coordination barriers identified by participants. Ultimately, participants agreed that no single agency can shoulder the entire “knee for life” journey; instead, a coordinated multi-sector approach is required. Bringing together ACC, healthcare providers, community sports clubs, workplaces, and whānau in a shared care framework will help ensure that people with ACL injuries do not fall through the cracks. By clarifying roles and enhancing communication among these groups, AoNZ’s support system can transition from its current culture of blame and siloed responsibility to one of collective accountability for long-term outcomes. Athlete identity and holistic rehabilitation outcomes The complex role of people’s identity in rehabilitation and recovery was another key insight within the findings. Participants noted that ACL injuries are often framed in sports-centric terms, with success defined by physical outcomes and a timely return to play. While physical recovery is undoubtedly essential, our findings suggest that overemphasising the athletic dimension can overlook patients’ broader well-being and personal goals. Our results indicate that a singular focus on athletics may clash with what patients want or need in the long term. Participants observed that not all individuals prioritise returning to high-level sport after ACLR; some young people, once back to work or daily life, do not prioritise continued intense training or decide to de-emphasize competitive sport altogether. This perspective aligns with evidence that a substantial proportion of ACL patients do not resume their previous sport at the same level; for example, only about 50–70% of athletes return to their pre-injury competitive level after undergoing ACLR ( 30 ). Whereas this may be interpreted as a poor rehabilitation outcome, our findings suggest that the “athlete” and individual mindset may dissolve as other priorities become the focus of well-being. Participants felt that outcomes should be measured more holistically than just physical metrics or speed of return to play. They advocated for defining “successful” recovery in collaboration with the patient, whether that means returning to competitive sport, transitioning to recreational activities, or simply achieving a pain-free knee for work and family life. This calls for a more patient-centred approach to rehabilitation that values psychosocial well-being and personal goal attainment alongside clinical measures aligning with prior qualitative work which highlighted the often-unaddressed psychosocial impacts of ACL injuries ( 3 ). Integrating sports psychology support, career/identity counselling, and goal setting into ACL injury rehabilitation programmes may improve engagement and long-term satisfaction. By broadening the concept of rehabilitation success beyond the athlete/non-athlete dichotomy, healthcare providers can better support the diverse trajectories and goals that individuals have after an ACL injury. Strengths and limitations This robust study using the Interpretive Description methodology enabled the generation of practical insights aligning with clinical and policy contexts. A notable strength was the diversity of perspectives achieved through the inclusion of multiple ethnic and end-user groups enabling enriched data and allowing triangulated observations across different roles in the support ecosystem of AoNZ. Regarding limitations, the study’s sample come from a single national context (AoNZ), with unique healthcare structures such as the ACC system, may restrict transferability; therefore, findings should be interpreted with awareness of local system differences. Furthermore, potential selection and response bias may exist, as participants who chose to engage might disproportionately represent more problem-focused views, although we addressed this through diverse recruitment and probing for positive experiences. Future research and knowledge mobilisation Future research should prioritise the development and evaluation of context-specific service models to support individuals at risk of PTOA following ACL injury in AoNZ. Co-designing these interventions with end-users will ensure contextual relevance and effectiveness, echoing findings by O’Brien et al. ( 31 ) on the need for end-user involvement in lifespan management planning. Research should also explore innovative knowledge mobilisation strategies to address gaps in awareness of long-term risks and self-care. Targeted education campaigns, improved resources, and delivery via social media and community networks may be effective for disseminating effective cohesive messaging ( 32 , 33 ). Conclusion This study highlights key implications for clinical practice, policy, and research in ACL injury, ACLR and PTOA management, emphasising that ACL injuries should be viewed as a lifelong evolving journey rather than self-limiting isolated events. Policymakers and funders, including ACC, should prioritise extended holistic care to delay PTOA onset, reduce long-term healthcare costs, and address identified inequities, particularly among high-risk groups such as Pacific communities. Clinically, adopting a multidisciplinary, transparent and patient-centred approach with enhanced collaboration through integrated care pathways is critical for improved patient outcomes. Future research should prioritise developing and evaluating integrated, context-specific care models in collaboration with end-users. Abbreviations Accident Compensation Corporation (ACC) Anterior cruciate ligament (ACL) Anterior cruciate ligament reconstruction (ACLR) Aotearoa New Zealand (AoNZ) Post-traumatic osteoarthritis (PTOA) Declarations Ethics approval and consent to participate The Auckland University of Technology Ethics Committee granted ethics approval (Approval number: 22/257). All participants gave written informed consent. Consent for publication Daniel W. O’Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis have approved the manuscript and consent to publication. Clinical trials number Not applicable. Competing interests The authors declare that they have no competing interests. Author contribution declaration Daniel W. O’Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis participated in the literature review, development of the research proposal, development of the participant interview schedule, data analysis, and manuscript preparation. Daniel O’Brien and Josie L. Timmins also participated in ethics application, data collection, and transcription. Funding Arthritis New Zealand funded this research. The funding body had no role in the study's design, data collection, analysis, interpretation, or manuscript writing. Author Contribution Daniel W. O’Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis participated in the literature review, development of the research proposal, development of the participant interview schedule, data analysis, and manuscript preparation.Daniel O’Brien and Josie L. Timmins also participated in ethics application, data collection, and transcription. Acknowledgements Not applicable. Data Availability The dataset used and analysed during the current study is available from the corresponding author upon reasonable request. References Filbay SR, Skou ST, Bullock GS, Le CY, Räisänen AM, Toomey C, et al. 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. Br J Sports Med. 2022;56(24):1465–74. Harkey MS, Baez S, Lewis J, Grindstaff TL, Hart J, Driban JB, et al. Prevalence of Early Knee Osteoarthritis Illness Among Various Patient-Reported Classification Criteria After Anterior Cruciate Ligament Reconstruction. Arthritis Care Res (Hoboken; 2021. O'Brien D, Rabey M, Reid D, Ellis R, Wilson Uluinayau T, Whittaker JL. The well-being of people with anterior cruciate ligament rupture-related post-traumatic osteoarthritis in Aotearoa New Zealand. BMC Musculoskelet Disord. 2025;26(216). Friel NA, Chu CR. The Role of ACL Injury in the Development of Posttraumatic Knee Osteoarthritis. Clin Sports Med. 2013;32(1):1–12. McCammon J, Zhang Y, Prior H, Leiter J, MacDonald J. Incidence of Total Knee Replacement in Patients With Previous Anterior Cruciate Ligament Reconstruction. Clin J Sport Med. 2021;31(6):e442–6. Kilanowski JF. Breadth of the Socio-Ecological Model. J Agromed. 2017;22(4):295–7. New Zealand ACL registry. New Zealand ACL Registry Annual Report. 2024 2024 [Available from: https://www.aclregistry.nz/reports/ Love H, Clatworthy M, Barker D. Injuries in New Zealand: Insights from 2024: How we’re getting hurt and how you can make a difference. 2024. Ministry of Health. Tupa Ola Moui: Pacific Health Chart Book 2025: Volume 1: Pacific Population in New Zealand Wellington: Ministry of Health; 2025 [Available from: https://www.health.govt.nz/system/files/2025-05/tupu-ola-moui-volume-1-pacific-population-new-zealand-v2.pdf Pryymachenko Y, Wilson R, Abbott JH. Epidemiology of cruciate ligament injuries in New Zealand: Exploring differences by ethnicity and socioeconomic status. Injury Prev. 2023;29(3):213–8. Whittaker JL, Truong LK, Losciale JM, Silverster-Lee T, Miciak M, Pajkic A, et al. Efficacy of the SOAR knee health program: protocol for a two-arm stepped-wedge randomized delayed-controlled trial. BMC Musculoskelet Disord. 2022;23(1):85. Truong LK, Mosewich AD, Holt CJ, Le CY, Miciak M, Whittaker JL. Psychological, social and contextual factors across recovery stages following a sport-related knee injury: A scoping review. Br J Sports Med. 2020;54(19):1149–56. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Thorne S. Interpretive description. Walnut Creek. California: Left Coast; 2008. p. 272. Terry G, Hayfield N. Essentials of thematic analysis. American Psychological Association; 2021. Boon-Nanai JM, Ponton V, Haxell A, Rasheed A. Through Pacific/ Pasifika lens to understand student's experiences and promote success within New Zealand tertiary environment. Sociol Study. 2017;7(6):293–314. Thorne S. Interpretive Description: Qualitative research for applied practice. Second ed. New York, New York. London, England.2016. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Res Psychol. 2006;3(2):77–101. Hunt MR. Strengths and challenges in the use of interpretive description: Reflections arising from a study of the moral experience of health professionals in humanitarian work. Qual Health Res. 2009;19(9):1284–92. Holm PM, Simonÿ C, Brydegaard NK, Høgsgaard D, Thorborg K, Møller M, et al. An early care void: The injury experience and perceptions of treatment among knee-injured individuals and healthcare professionals - A qualitative interview study. Phys Ther Sport. 2023;64:32–40. Whittaker JL, Runhaar J, Bierma-Zeinstra S, Roos EM. A lifespan approach to osteoarthritis prevention. Osteoarthritis Cartilage. Dec 2021;29(12):1638–53. Truong LK, Mosewich AD, Holt CJ, Le CY, Miciak M, Whittaker JL. Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review. Br J Sports Med. 2020;54(19):1149–56. Truong LK, Mosewich AD, Miciak M, Pajkic A, Le CY, Li LC, et al. Balance, reframe, and overcome: The attitudes, priorities, and perceptions of exercise-based activities in youth 12–24 months after a sport-related ACL injury. J Orthop Res. 2022;40(1):170–81. Truong LK, Mosewich AD, Miciak M, Losciale J, Li LC, Whittaker JL. Social support and therapeutic relationships intertwine to influence exercise behavior in people with sport-related knee injuries. Physiother Theory Pract. 2025;41(1):139–52. Durie MH. A Maori perspective of health. Soc Sci Med. 1985;20(5):483–6. Pulotu-Endemann FK. Fonofale model of health Wellington, New Zealand: Ministry of Health; 1995 [Available from: https://d3n8a8pro7vhmx.cloudfront.net/actionpoint/pages/437/attachments/original/1534408956/Fonofalemodelexplanation.pdf?1534408956 Dixon TW, O’Brien DW, Terry G, Baldwin JN, Ruakere T, Mekkelholt T, et al. The Lived Experiences of Ngā Tāne Māori with Hip and Knee Osteoarthritis. New Z J Physiotherapy. 2021;49(3):127–33. McGruer N, Baldwin JN, Ruakere BT, Larmer PJ. Māori lived experience of osteoarthritis: a qualitative study guided by Kaupapa Māori principles. J Prim Health Care. 2019;11(2):128–37. Te Kāwanatanga o Aotearoa New Zealand Government. Treatment under our Integrated Care Pathway 2024, 16 October [Available from: https://www.acc.co.nz/im-injured/types-of-ongoing-support/integrated-care-pathways#:~:text=required%20treatments%20to%20help%20you,your%20cultural%20needs%20are%20met Manojlovic M, Ninkovic S, Matic R, Versic S, Modric T, Sekulic D, et al. Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review of Recent Evidence. Sports Med. 2024;54(8):2097–108. O’Brien D, Rabey M, Reid D, Ellis R, Uluinayau TW, Whittaker J. Exploring the long-term well-being of peoples following anterior cruciate injury in Aotearoa New Zealand. Osteoarthritis Cartilage. 2025;33:S207. Baran RV, Fazari M, Lightfoot D, Cusimano MD. Social media strategies used to translate knowledge and disseminate clinical neuroscience information to healthcare users: A systematic review. PLOS Digit Health. 2025;4(4):e0000778. Roland D, Social Media H, Policy, Translation K. J Am Coll Radiol. 2018;15(1, Part B):149 – 52. Additional Declarations No competing interests reported. Supplementary Files OBrienetalACLPTOAManuscriptBMCMSKAdditionalfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 Jan, 2026 Reviewers invited by journal 16 Jan, 2026 Editor invited by journal 19 Dec, 2025 Editor assigned by journal 17 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 15 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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09:28:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27135,"visible":true,"origin":"","legend":"","description":"","filename":"OBrienetalACLPTOAManuscriptBMCMSKAdditionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8370277/v1/6ed8e68ca4aba0e28da439fd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the support environment for people following anterior cruciate ligament injury in Aotearoa New Zealand","fulltext":[{"header":"Background","content":"\u003cp\u003eACL injuries have a significant health impact in AoNZ, with a high and rising incidence that, despite surgical reconstruction (ACLR), continues to result in elevated levels of symptoms and disabilities for individuals\u0026rsquo; years post-surgery (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). ACL injuries the lives of typically young, active individuals, often requiring lengthy rehabilitation combined with ACLR, which interferes with participation in sports, daily activities and overall well-being (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The long-term impact of ACL injury on people in AoNZ extend well beyond the immediate trauma of ligament rupture, surgery, and rehabilitation where consequences can include changes to mood, confidence, and self-perception as well as severe impacts of loss of employment (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). One of the most serious outcomes of ACL injury is the significantly elevated risk of PTOA in the affected knee. While estimates vary, several studies suggest that approximately half of the individuals who sustain an ACL injury develop knee osteoarthritis within 10\u0026ndash;20 years (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These injuries typically affect young adults, meaning many people from AoNZ may have PTOA by mid-life and face a higher likelihood of requiring knee replacement than those without prior ACL injury (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Thus, an ACL injury is not merely an acute setback but a potential catalyst for chronic joint deterioration and long-term disability (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eImportantly, rehabilitation and recovery after ACL injury and ACLR do not occur in isolation but within a socioecological context (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). AoNZ\u0026rsquo;s healthcare system offers universal no-fault injury coverage via Accident Compensation Corporation (ACC), ensuring access to healthcare and income compensation following ACL injuries. There are approximately 3,000 ACLRs annually with ACC spending around NZ\u003cspan\u003e$\u003c/span\u003e14,000 on the recovery of each one (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). However, significant ethnic and socioeconomic disparities in ACL injury incidence and care have been noted across communities. For example, in AoNZ, Pacific peoples (who make up 8.9% of the population(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)) have the highest ACL injury rates and personal factors such as access to physiotherapy, health knowledge, and motivation can significantly influence rehabilitation adherence and outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). These factors underscore that effective ACL injury management requires a holistic approach attuned to the surrounding context as multiple influences impact on a patient\u0026rsquo;s recovery journey (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven this complex rehabilitation environment, the perspectives of end-users are crucial for fully understanding and improving ACL injury management. Health professionals commonly provide treatment and guidance; however, patients\u0026rsquo; experiences are supported by many other connections, such as whānau, employers, colleagues, friends, and sports coaches (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Furthermore, broader organisations and health systems influence rehabilitation and long-term impacts, such as advocacy groups (i.e., Arthritis New Zealand), funders and policymakers (i.e., ACC, Health New Zealand, Ministry of Health), which can shape the rehabilitation environment. Our recent work has called for greater end-user involvement in designing long-term ACL injury care strategies tailored to AoNZ\u0026rsquo;s context as little is known about what different groups expect from current ACL injury and ACLR rehabilitation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Capturing these experiences and perspectives is vital to inform more effective, contextually appropriate approaches to ACL injury and the medium- to long-term ACLR management in AoNZ.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch question and aim\u003c/h2\u003e \u003cp\u003eThis qualitative research explored the question, \u0026ldquo;\u003cem\u003eWhat are end-user perceptions and experiences of working with people with PTOA following ACL injury in the medium- to long-term in AoNZ?\u0026rdquo;\u003c/em\u003e to gain insights from various end-users into the medium- and long-term impact of ACL injury, ACL injury management, and PTOA in AoNZ.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDesign and ethics\u003c/h3\u003e\n\u003cp\u003eThis Interpretive Descriptive study was informed by a realist philosophical lens and followed the Consolidated Criteria for Reporting Qualitative Research (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) checklist and reporting guidelines. Interpretive Description was selected because it focuses on capturing subjective perceptions and understandings of health-related experiences and interpreting them to inform credible and meaningful clinical understanding (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Data were analysed using Reflexive Thematic Analysis, which allows the construction of inductive and latent themes, providing valuable insights into phenomena (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The Auckland University of Technology Ethics Committee approved this research (AUTEC #: 22/257) (Clinical trials number: not applicable).\u003c/p\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eWe aimed to purposively recruit 12\u0026ndash;15 end-users who have experience with the management of PTOA following ACL injury in AoNZ. Potential participants were recruited through direct contact via publicly available emails by one of the research team and via the snowball method (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), and invited to participate in an individual interview. We aimed for diversity in ethnicity, health profession, health sector role (managerial, policy, front-line), geographical area of work, and level of involvement with ACL and PTOA patients. Participants were excluded if they could not communicate in English.\u003c/p\u003e\n\u003ch3\u003eData generation\u003c/h3\u003e\n\u003cp\u003eParticipants were encouraged to share their beliefs about ACL injury management in AoNZ, including treatment, lasting impact, and service design and delivery during 30\u0026ndash;60-minute, face-to-face online interviews. The interviews were semi-structured to allow flexibility in exploring the participants' narratives while being guided by an interview schedule (Additional File 1) and the researchers\u0026rsquo; expertise and personal experience with ACLR and PTOA (DOB, JT). The schedule was adjusted iteratively as the study progressed based on participants' responses, development of issues, emerging observations, and a deeper understanding of the phenomenon (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Interviews were conducted between July and November 2023, video-recorded, and transcribed verbatim. The interviewer(s) (DOB and/or JT) wrote summary memos reflecting their thoughts after each interview, which were included in the data synthesis and theme construction. Participants had the opportunity to review the transcripts and give feedback on accuracy.\u003c/p\u003e\n\u003ch3\u003eResearcher Positionality and Paradigm\u003c/h3\u003e\n\u003cp\u003eInterviewers DOB (male) and JT (female) were from AoNZ, were experienced qualitative health researchers, and registered physiotherapists with extensive ACL injury and ACLR rehabilitation experience professionally and personally. Subthemes and themes were presented to the broader research team, who, while all physiotherapists, brought a range of experiences and viewpoints including working extensively with Māori and Pacific peoples; elite sport; ACL research; and professional and personal ACL injury, ACLR and PTOA experience.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analysed using Reflexive Thematic Analysis, a flexible approach that enables a rich, detailed, and complex account of the data and allowing themes to be developed that are applicable for clinical practice (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Data collection and analysis were carried out concurrently, allowing insights developed during earlier interviews to be checked in later interviews, presenting opportunities to refine the research and reorient the inquiry according to developing insights (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo researchers (DOB, JT) manually coded all transcripts. Inductive coding allowed meaning to be grounded in the data (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Latent codes were generated following the recommendations of Terry and Hayfield (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), capturing meaningful data interpretations, followed by independent theme and subtheme development through active pattern formation and identification. The researchers returned to the raw data and initial coding recursively to ensure a deep level of interpretation and that the analysis related to the research question (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Ongoing collaboration with the wider research team occurred before the final themes and theme names were decided. Participant quotes illustrative of constructed themes are included in the findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSixteen people with a broad range of ACL injury (acute ACL ruptures, re-ruptures and ACL surgery) and PTOA management experience (18 months to over 30 years as clinicians and support persons) participated in the study (see Table 1). Most were women and of New Zealand European ethnicity. However, two participants did identify as Māori and two with Sāmoan ethnicity. Participants were from a range of major urban centres around AoNZ: Auckland, Hawkes Bay, Wellington, and Christchurch, affiliated with organisations such as Arthritis New Zealand, ACC, Te Whatu Ora, Te Aka Whai Ora, High Performance Sport, Netball New Zealand, and Moana Pasifika, and encompassed a wide range of roles from coaching and parenting to physiotherapy, sports medicine, surgery, and organisational leadership. All participants were provided copies of their interview transcripts, with minimal amendments requested.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Participant Characteristics (n=16)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 429px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e \u003cem\u003en\u003c/em\u003e (%) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eWomen\u003c/p\u003e\n \u003cp\u003eMen\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (56) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7 (44) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 429px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e \u003cem\u003en\u003c/em\u003e (%) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNew Zealand European \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMāori\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eAsian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSāmoan/ Japanese\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSāmoan/ New Zealand European\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSouth African\u003c/p\u003e\n \u003cp\u003eNo response\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9 (56) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (13) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 429px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRoles\u003c/strong\u003e \u003cem\u003en\u003c/em\u003e (%) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePhysiotherapist\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eParent\u003c/p\u003e\n \u003cp\u003ePhysician\u003c/p\u003e\n \u003cp\u003eChief Executive Officer\u003c/p\u003e\n \u003cp\u003eCoach\u003c/p\u003e\n \u003cp\u003eManager\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eMusculoskeletal Project Facilitator \u0026nbsp;\u003c/p\u003e\n \u003cp\u003eOrganisation Co-Chair\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrinciple Advisor\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eSurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 135px;\"\u003e\n \u003cp\u003e \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (31) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (13)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (13) \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cu\u003eIdentified Themes\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe constructed four themes from the data: 1) \u003cem\u003eKnee for life: Supporting the whole journey,\u0026nbsp;\u003c/em\u003e2)\u003cem\u003e\u0026nbsp;Care beyond the clinic, 3)\u003c/em\u003e \u003cem\u003eThe blame game\u003c/em\u003e, and 4) \u003cem\u003eShifting the goal posts: Beyond athletes and sport.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eKnee for life:\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003cem\u003e\u003cu\u003eSupporting the whole journey\u003c/u\u003e\u003c/em\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis theme draws on participants\u0026rsquo; perceptions that ACL injuries are arguably managed well at the time of injury yet have long-term consequences that are sometimes underemphasised or neglected by certain healthcare providers. Participants expressed concern that rehabilitation was lacking for patients outside the commonly practised ACL rehabilitation timeline of nine to twelve months post-injury, with or without surgery, which affected their long-term care. For example, one participant said, \u003cem\u003e\u0026ldquo;After that period of time [initial rehab], in the New Zealand system, I\u0026apos;m not sold we do a lot for those patients.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3, physiotherapist). Concerns were expressed that gaps appeared where patients prematurely lost access to medical care following their ACL surgery rehabilitation: \u003cem\u003e\u0026ldquo;I think it\u0026apos;s 12-month check-in, maybe 6 to 12 months\u0026hellip;And really nothing else happens after that. And so, you\u0026apos;re left on your own.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 1). Moreover, subsequent knee issues that arose after rehabilitation ended were unexpected for patients, with participants reporting that patients had difficulties managing their care at this stage: \u003cem\u003e\u0026ldquo;Suddenly, a person, potentially around 30, mid-30s, is starting to have that [knee] issue. And for a lot of them, that will be an absolute bolt out of the blue.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 1).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis gap in care also highlighted the lack of long-term education that patients receive. Initial education and messaging can be chaotic, overwhelming, and devoid of information about long-term ACL injury and PTOA management.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;One of the things I\u0026apos;m not sure we do well enough, whether it be in ACLs or musculoskeletal physiotherapy full stop, is educating our patients enough about what it means here and now and what it means for the future.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, participants recognised that patients also carry responsibility and often do not understand or prioritise the long-term effects of a knee injury, reporting \u003cem\u003e\u0026ldquo;We don\u0026apos;t think about our future self.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4). Participants perceived patients desired quick solutions and were not always focused on comprehensive rehabilitation: \u003cem\u003e\u0026ldquo;Quick fixes, get back on the field, what do I need to do that?\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 14).\u003cem\u003e\u0026nbsp;\u003c/em\u003eFurther adding to this sentiment, one participant (a physiotherapist) appeared to assume that poor patient engagement in long-term care indicated the patient had met all their rehabilitation targets: \u003cem\u003e\u0026ldquo;I\u0026apos;m assuming they\u0026apos;re getting back and running around doing alright.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 5).\u003c/p\u003e\n\u003cp\u003eHowever, many participants felt that long-term care and education were necessary for these individuals. One participant (a mother) reported: \u003cem\u003e\u0026ldquo;I couldn\u0026apos;t have imagined having her just discharged from the physio and that was that. Like, I felt like we would have needed to go back on a regular basis, even if it was just every couple of months.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 12). Several participants emphasised the need for long-term care, recommending regular post-injury check-ins with screenings to address knee concerns: \u003cem\u003e\u0026ldquo;And do we look at some preventative screening at certain intervals along that pathway? Yeah. That would be of benefit.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSolutions were also provided as participants perceived long-term care to be enhanced and nurtured through \u003cem\u003ewhakawhanaungatanga\u003c/em\u003e (relationship building). Creating spaces of trust and partnership can empower patients to manage their knees more effectively: \u003cem\u003e\u0026ldquo;You build up quite a relationship with that patient and often their whānau as well, depending how old that patient might be and therefore how involved the family are.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3); and \u003cem\u003e\u0026ldquo;So again, that therapeutic relationship. If you say to somebody towards the end of their treatment, \u0026lsquo;If things aren\u0026apos;t working, come back\u0026rsquo; is probably the biggest single thing that people would need. Is that kind of permission to come back.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 5).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eCare beyond the clinic\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis theme recognises that social support and community involvement are crucial to patient care in the short- to medium-term. Participants reported ACL injury and PTOA rehabilitation as heavily individualistic and collaboration outside immediate medical care can be overlooked \u003cem\u003e\u0026ldquo;The way our system looks at it, it looks at an individual. It doesn\u0026apos;t look at whānau.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 7). The physical health approach to ACL injury and PTOA care continued to dominate and restrict alternative views of health. \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When you\u0026apos;re part of a team, you\u0026apos;re a piece of the puzzle. With this, I was individual. I really struggled the first time mentally. Everyone said you were going to be fine. And in the sense that you\u0026apos;re physically going to get fine.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 16, coach).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, models that enhance social support for patients through sports teams, community organisations, and rehabilitation programmes should be explored and embraced. Participants believed that a more collective community and social approach helped health services deliver essential holistic care: \u003cem\u003e\u0026ldquo;I think the social aspect of people with a chronic condition is really important. And maybe having that support would have been better on our programmes.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 1, physiotherapist). Holistic care is portrayed well by one participant, a Māori health manager and practitioner, who reported the need to look at the whole person to provide necessary healing:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So wairuatanga, the mauri, the tapu, the mana (the layers forming the essence of the person). And so, depending on which thing is impacted with the person, is where we\u0026apos;ll interact with them to strengthen a connection and get in sync, and then help them to heal themselves.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 7).\u003c/p\u003e\n\u003cp\u003eThe benefit of social connections and how this approach was significantly beneficial for the patient\u0026rsquo;s journey and outcome success was frequently mentioned during the interviews, within the high-performance environment\u003cem\u003e\u0026nbsp;\u0026ldquo;You see the elite ones, the Mystics [provincial netball team] or New Zealand [national netball team], and you see the players in the stand or still part of the team from that perspective.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 16); and grass-roots level \u003cem\u003e\u0026ldquo;Her club netball coach was amazing. Kept her involved, kept her with the team.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 12, parent); and \u003cem\u003e\u0026ldquo;Telling the team that she is still part of the team, even though she\u0026apos;s injured, \u0026lsquo;You need to support her, and she\u0026apos;s still part of what we do\u0026rsquo;.\u0026rdquo;\u003c/em\u003e (Participant 16, coach). However, in general the social care provided by high-performance clubs did not regularly appear to transfer to the grass-roots level, with the experiences of Participant 12 and 16 being outliers and considered to be due to an individual rather than a club-wide value. Although participants perceived sports teams and clubs as influencing their players\u0026apos; journey and outcome, they appeared hesitant to engage with health rehabilitation: \u003cem\u003e\u0026ldquo;They\u0026apos;ve got a part to support the ongoing welfare of their players. And we\u0026apos;ve seen a lot of older players who have not been supported or could have been supported better.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reported that families also have roles to play in providing support. One participant, a parent, spoke on the social role she provided: \u003cem\u003e\u0026ldquo;My role was more about economic support. The partner was very good with emotional support\u0026rdquo;;\u0026nbsp;\u003c/em\u003eand \u003cem\u003e\u0026ldquo;The vā feagaiga (relational bond between brother and sister), they have to support her in whatever way she needs it.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 13). Ultimately, injury management cannot be placed solely on the individual, rather it is a shared role with health professionals and the wider community and essential in the short- to medium-term.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eThe blame game\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe \u0026lsquo;blame game\u0026rsquo; underscores the financial and hierarchical conflicts surrounding ACL injury and PTOA rehabilitation, the effects of limited ACC funding, and the reluctance of external services to accept responsibility. Funding and ACC were consistently emphasised throughout the interviews as participants firmly believed that ACC was central to ACL injury and PTOA care and barriers to funding as unjust: \u003cem\u003e\u0026ldquo;I think ACC has to be roped in because ACL injuries are ACC injuries, plain and simple.\u0026rdquo;\u003c/em\u003e (Participant 2); and \u003cem\u003e\u0026ldquo;I think cost is probably the biggest barrier for most people.\u0026rdquo;\u003c/em\u003e (Participant 15). Funding challenges were so unjust that to provide necessary care one participant reported risking their ethical responsibilities: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There\u0026apos;s ten people in the way of you getting help for your knee. Whereas, if I sign an ACC form, there\u0026apos;s no one in the way. Hence, everyone turning up, and people like myself turning a blind eye to the law and our ethics and all other things and getting them some help.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was also a common perception that ACC held tight purse strings and was ignorant to the full scope of patient care: \u003cem\u003e\u0026ldquo;I get it because ACC has got to deliver on what ACC is. But that\u0026apos;s not necessarily helping the health of our nation.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBlame for inadequate patient care was also attributed to the dominant hierarchical power and influence of surgeons. Participants felt that surgeons and senior management held dated views on rehabilitation: \u003cem\u003e\u0026ldquo;A lot of these surgeons feel physio is not needed. They do the knee replacement; the patient will be fine.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 2).\u003cem\u003e\u0026nbsp;\u003c/em\u003eIn addition to surgeons and senior management\u0026rsquo;s absolute authority to enact these views, one participant stated:\u003cem\u003e\u0026nbsp;\u0026ldquo;There\u0026apos;s no check in the system, a SMO [senior medical officer] has the power and the authority to do that, and they do that unchecked.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 7).\u0026nbsp;Turf wars, where professions cling tightly to their individual areas of practice, were also perceived to be prevalent and contributing to inadequate patient care:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Orthopaedics, without sounding too controversial, is a white males club, and they are particularly patch protective. They\u0026apos;re an arrogant group of people. Confident, arrogant, whichever way you want to put it. And they struggle enough taking referrals from physiotherapists, let alone taking referrals from people that, in their opinion, would have no health background.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA delicate dance was believed to be necessary to begin addressing the power imbalances and to challenge the progressive views on rehabilitation: \u003cem\u003e\u0026ldquo;I don\u0026apos;t think we sideline them [surgeons], but we\u0026apos;ve got to get them on side. And get them to start to understand the distribution of power.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 3).\u003c/p\u003e\n\u003cp\u003eWith blame firmly placed on limited funding and power dynamics, the acceptance of the absence of outside services to take accountability tended to be normalised within sports systems: \u003cem\u003e\u0026ldquo;I don\u0026apos;t think Sport New Zealand will be interested because, as I say, their focus is up to 18 [years old], and they\u0026apos;ve pushed back a lot on other areas where they sort of haven\u0026apos;t seen it their business.\u0026rdquo;\u003c/em\u003e (Participant 1); educational systems \u003cem\u003e\u0026ldquo;Teachers are overwhelmed and can\u0026apos;t do anything additional, [that] is their starting position.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 10); and workplaces \u003cem\u003e\u0026ldquo;Because we\u0026apos;ve got a bit of a double-edged sword. We want people back at work, but employers don\u0026apos;t want to carry risk.\u0026rdquo;\u003c/em\u003e (Participant 5.)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, participants recognised the need for outside services to be involved, understanding that no single service should bear all the responsibility or burden including sports clubs: \u003cem\u003e\u0026ldquo;I still think individual things like rugby, some of the clubs, and the sports could actively be a real participant in this whole engagement. As we talked about, how do we keep them involved in the game?\u0026rdquo;\u003c/em\u003e (Participant 1); and schools\u003cem\u003e\u0026nbsp;\u0026ldquo;Schools should be a lot more supportive of school kids when they have injuries.\u0026rdquo;\u003c/em\u003e (Participant 16).\u003c/p\u003e\n\u003cp\u003eParticipants also felt that patients needed to take accountability, to stop heavily relying on ACC, and be realistic about their own care: \u003cem\u003e\u0026ldquo;This is a journey that doesn\u0026apos;t finish once ACC stops funding you. You need to carry on being accountable yourself, for looking after yourself as well.\u0026rdquo;\u003c/em\u003e (Participant 8); and take personal responsibility for their own well-being, reducing reliance on overworked and underfunded health systems: \u003cem\u003e\u0026ldquo;The first one ruptured her ACL the first game back after her having had 10 years away from netball. Did the quick run, a cursory stretch, and a couple of lunges for old times\u0026apos; sake.\u0026rdquo;\u003c/em\u003e (Participant 8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eShifting the goal posts: Beyond athletes and sport\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis theme was characterised by the prominence of sport and athlete models of care in ACL injury management, where care and successful outcomes should extend beyond the physical aspects and more closely reflect holistic measures and patients\u0026apos; personal goals. Participants often described the ACL injury world through a sporting lens, referring to patients as athletes: \u003cem\u003e\u0026ldquo;\u0026hellip;like a 40-year-old athlete who wants to get another season or something.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4). Furthermore, physical health was viewed as central to patient care, in alignment with the design of health systems. Participants described rehabilitation for ACL injuries and PTOA, emphasising physical and objective measures: \u003cem\u003e\u0026ldquo;How do you protect these guys for longer to push away the knee replacement? That\u0026apos;s probably strength and range of movement work.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4); and \u003cem\u003e\u0026ldquo;We\u0026apos;ve got really good systems and structures in place to ensure that we\u0026apos;re not returning patients prematurely to a situation they\u0026apos;re not ready for from a physical perspective.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 15). However, participants also reported that physical goals and returning to sport were not always prioritised by patients, and they acknowledged a need to look beyond physical health and sport as the perception of outcome success.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;That sort of six to nine months is the most important time, really, because that\u0026apos;s where we get our strength up so that we can have at least 90% of the function to our opposite leg, right? And so, it\u0026apos;s funny. That\u0026apos;s almost, debatably, the most important part for the physio, but it\u0026apos;s the least important part for the patient...\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 6, physiotherapist).\u003c/p\u003e\n\u003cp\u003eParticipants also found engagement improved when outcome success was viewed from the patient\u0026apos;s perspective, placing their goals at the centre of rehabilitation. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We can engage them until a point they get to where they wanted to get to. So, if that\u0026apos;s back on the field, great. If it\u0026apos;s back at work or it\u0026apos;s back out of pain, everyone\u0026apos;s got a different target.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 4, surgeon).\u003c/p\u003e\n\u003cp\u003eArguably, the sporting identity and platform that sport holds in ACL injury care appear to be shifting. Participants reported that sports and sporting stars are no longer viewed as the best way to advertise care, and are instead looking towards more community-focused, realistic daily activities: \u003cem\u003e\u0026ldquo;I\u0026apos;m not sure that they are the best role models, thinking of your Michael Jones [rugby sporting star] example [laughter], are they the best models? Perhaps not.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 5); and\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve seen all the \u0026lsquo;have a hmmm\u0026rsquo; ads, the ACC ads. And I was like, \u0026lsquo;Man, those are much better now.\u0026rsquo; And I think they\u0026apos;ve won awards for them, actually. It makes sense, though, because you\u0026apos;ve got that whānau element.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(Participant 6).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored diverse perspectives on the medium- to long-term impacts of ACL injury and PTOA in AoNZ from a wide group of end-users. The findings indicate that an ACL injury is not just an acute event but the beginning of a \u0026ldquo;knee for life\u0026rdquo; journey, with consequences that extend well beyond initial treatment. Participants identified four interrelated themes: long-term implications of ACL injuries, a \u0026ldquo;blame game\u0026rdquo; around funding and responsibility, the influence of athletic identity on rehabilitation, and the importance of community engagement and social support. Together, these themes address our research question by highlighting that effective long-term management of ACL injuries requires attention to lifelong knee health, more transparent accountability across health and social systems, consideration of patients\u0026rsquo; identities and goals, and stronger community and whānau support. In summary, the broader support environment for people after ACL injury in AoNZ appears fragmented and underprepared to meet the \u0026ldquo;knee for life\u0026rdquo; challenge, underscoring the need for more cohesive, patient-centred strategies.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLong-term implications and continuity of care\u003c/h2\u003e \u003cp\u003eParticipants described how ACL injuries often set the stage for chronic knee issues, yet medium- to long-term follow-up and education are lacking. Despite generally good acute management, participants noted a post-rehabilitation void where patients are \u0026ldquo;left on [their] own\u0026rdquo; after the typical 9 to 12-month rehabilitation period. This reflects a health system culture that prioritises immediate recovery milestones (e.g., return to sport or work), but underemphasises ongoing surveillance and secondary prevention of knee osteoarthritis. Participants lamented that patients are seldom warned about this high PTOA risk or equipped with long-term self-management strategies. This finding aligns with recent qualitative research by O\u0026rsquo;Brien et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), where individuals over five years post-ACL injury reported that \u0026ldquo;nobody ever told\u0026rdquo; them about the likelihood of osteoarthritis and wished they had more guidance on long-term knee care. Holm et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) also found ACL injured individuals in Denmark were not provided adequate long-term education causing mixed views on the future of their knees. Both patients and participants thus identify a critical gap in continuity of care. Providers may assume a patient is \u0026ldquo;doing all right\u0026rdquo; once formal rehabilitation ends, yet participants observed that knee problems often resurface unexpectedly later. The \u0026ldquo;Knee for Life\u0026rdquo; theme aligns with previous research which emphasises that an ACL injury should be viewed as a lifelong condition, necessitating preventive interventions, and patient education that extend well beyond the initial rehabilitation period (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCommunity engagement, social support, and equity\u003c/h2\u003e \u003cp\u003eThe \u0026ldquo;Care beyond the clinic\u0026rdquo; theme underscores that successful long-term adaptation to ACL injury is not solely a medical endeavour but a social one. Participants in our study stressed that early intervention from the wider community, including sports clubs, teams, schools, employers, and whānau, play a pivotal role in a person\u0026rsquo;s rehabilitation journey and well-being. However, current systems often adopt an individualistic approach, where formal rehabilitation focuses on the patient in isolation. Participants noted that community resources and social networks are underutilised; for instance, grassroots sports clubs rarely have formal programmes to keep injured players involved, despite the benefits seen by some coaches who supported injured players with team roles. This finding aligns with the literature, which indicates that social support has wide-ranging effects on recovery, influencing emotional well-being, motivation, exercise participation, and physical outcomes (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), and adequate support from family, friends, and peers can buffer psychological stress after ACL injury, while social isolation or lack of understanding can hinder rehabilitation (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMāori and Pacific models of health emphasise holistic considerations including collectivism, relationships, and spiritual well-being. Ensuring all elements maintain balance is central to recovery or a form of homeostasis (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). As reported by participants, cultural concepts including whanaungatanga and \u0026ldquo;vā feagaiga\u0026rdquo; were considered fundamental to healing in Māori and Sāmoan worldviews, ensuring patients feel connected and fully supported in their journey. Our findings suggest that implementing Māori and Pacific principles of care could enhance the experience and outcomes for people with ACL injuries, particularly for the AoNZ environment (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, attention to equity is crucial. Pacific peoples in AoNZ have the highest incidence of ACL injuries and associated costs with significant ethnic and socioeconomic disparities in ACL injury outcomes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These inequities mean that those already underserved by the health system are at risk of worse long-term consequences. Our participants advocated moving beyond professional \u0026ldquo;turf wars\u0026rdquo; and fostering partnerships across health, sports, and community sectors. By leveraging community strengths (such as the camaraderie of a team or the caregiving roles of whānau) and embedding support within a patient\u0026rsquo;s everyday life context, the broader support environment can become more inclusive and effective in ACL injury management, long-term knee health and overall well-being.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSystem fragmentation, funding, and accountability\u003c/h2\u003e \u003cp\u003eThe \u0026ldquo;blame game\u0026rdquo; theme revealed participant frustrations with fragmentation in the support system and ambiguity in responsibility for long-term ACL injury management. Participants frequently pointed to AoNZ\u0026rsquo;s no-fault injury compensation system, ACC as essential and yet limiting. ACC provides universal coverage for acute injury care, but its funding constraints and episodic structure may leave those with chronic post-ACL issues in limbo. Many noted that once ACC-funded rehabilitation or wage compensation ends, patients can struggle to access further support, feeling abandoned by the system, a finding that resonates with broader concerns about silos and service fragmentation in injury care (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Participants described a tendency for various end-users to operate in isolation, often assuming that someone else will take charge of the patient\u0026rsquo;s healthcare coordination and long-term well-being. Indeed, our participants saw a \u0026lsquo;passing of the buck\u0026rsquo;. For example, surgeons focus narrowly on surgical outcomes, while community or sports groups hesitate to assume any formal role post-rehabilitation, and physiotherapists do not consistently offer longer-term care and guidance. Such fragmentation not only frustrates providers but also exacerbates inequities in care continuity. If patients lack personal resources or knowledgeable advocates, they are less likely to navigate the gap between acute care and chronic management.\u003c/p\u003e \u003cp\u003eOur findings underline the need for more integrated and accountable care pathways. ACC has recently introduced an Integrated Care Pathway for musculoskeletal injuries that assigns patients a dedicated team and navigator to coordinate treatment from injury through recovery (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This model, which encompasses services beyond the initial injury episode, represents a promising step toward overcoming some funding and coordination barriers identified by participants. Ultimately, participants agreed that no single agency can shoulder the entire \u0026ldquo;knee for life\u0026rdquo; journey; instead, a coordinated multi-sector approach is required. Bringing together ACC, healthcare providers, community sports clubs, workplaces, and whānau in a shared care framework will help ensure that people with ACL injuries do not fall through the cracks. By clarifying roles and enhancing communication among these groups, AoNZ\u0026rsquo;s support system can transition from its current culture of blame and siloed responsibility to one of collective accountability for long-term outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eAthlete identity and holistic rehabilitation outcomes\u003c/h2\u003e \u003cp\u003eThe complex role of people\u0026rsquo;s identity in rehabilitation and recovery was another key insight within the findings. Participants noted that ACL injuries are often framed in sports-centric terms, with success defined by physical outcomes and a timely return to play. While physical recovery is undoubtedly essential, our findings suggest that overemphasising the athletic dimension can overlook patients\u0026rsquo; broader well-being and personal goals.\u003c/p\u003e \u003cp\u003eOur results indicate that a singular focus on athletics may clash with what patients want or need in the long term. Participants observed that not all individuals prioritise returning to high-level sport after ACLR; some young people, once back to work or daily life, do not prioritise continued intense training or decide to de-emphasize competitive sport altogether. This perspective aligns with evidence that a substantial proportion of ACL patients do not resume their previous sport at the same level; for example, only about 50\u0026ndash;70% of athletes return to their pre-injury competitive level after undergoing ACLR (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Whereas this may be interpreted as a poor rehabilitation outcome, our findings suggest that the \u0026ldquo;athlete\u0026rdquo; and individual mindset may dissolve as other priorities become the focus of well-being.\u003c/p\u003e \u003cp\u003eParticipants felt that outcomes should be measured more holistically than just physical metrics or speed of return to play. They advocated for defining \u0026ldquo;successful\u0026rdquo; recovery in collaboration with the patient, whether that means returning to competitive sport, transitioning to recreational activities, or simply achieving a pain-free knee for work and family life. This calls for a more patient-centred approach to rehabilitation that values psychosocial well-being and personal goal attainment alongside clinical measures aligning with prior qualitative work which highlighted the often-unaddressed psychosocial impacts of ACL injuries (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Integrating sports psychology support, career/identity counselling, and goal setting into ACL injury rehabilitation programmes may improve engagement and long-term satisfaction. By broadening the concept of rehabilitation success beyond the athlete/non-athlete dichotomy, healthcare providers can better support the diverse trajectories and goals that individuals have after an ACL injury.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis robust study using the Interpretive Description methodology enabled the generation of practical insights aligning with clinical and policy contexts. A notable strength was the diversity of perspectives achieved through the inclusion of multiple ethnic and end-user groups enabling enriched data and allowing triangulated observations across different roles in the support ecosystem of AoNZ.\u003c/p\u003e \u003cp\u003eRegarding limitations, the study\u0026rsquo;s sample come from a single national context (AoNZ), with unique healthcare structures such as the ACC system, may restrict transferability; therefore, findings should be interpreted with awareness of local system differences. Furthermore, potential selection and response bias may exist, as participants who chose to engage might disproportionately represent more problem-focused views, although we addressed this through diverse recruitment and probing for positive experiences.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eFuture research and knowledge mobilisation\u003c/h2\u003e \u003cp\u003eFuture research should prioritise the development and evaluation of context-specific service models to support individuals at risk of PTOA following ACL injury in AoNZ. Co-designing these interventions with end-users will ensure contextual relevance and effectiveness, echoing findings by O\u0026rsquo;Brien et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) on the need for end-user involvement in lifespan management planning. Research should also explore innovative knowledge mobilisation strategies to address gaps in awareness of long-term risks and self-care. Targeted education campaigns, improved resources, and delivery via social media and community networks may be effective for disseminating effective cohesive messaging (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights key implications for clinical practice, policy, and research in ACL injury, ACLR and PTOA management, emphasising that ACL injuries should be viewed as a lifelong evolving journey rather than self-limiting isolated events. Policymakers and funders, including ACC, should prioritise extended holistic care to delay PTOA onset, reduce long-term healthcare costs, and address identified inequities, particularly among high-risk groups such as Pacific communities. Clinically, adopting a multidisciplinary, transparent and patient-centred approach with enhanced collaboration through integrated care pathways is critical for improved patient outcomes. Future research should prioritise developing and evaluating integrated, context-specific care models in collaboration with end-users.\u003c/p\u003e"},{"header":"Abbreviations","content":" \u003cp\u003eAccident Compensation Corporation (ACC)\u003c/p\u003e \u003cp\u003eAnterior cruciate ligament (ACL)\u003c/p\u003e \u003cp\u003eAnterior cruciate ligament reconstruction (ACLR)\u003c/p\u003e \u003cp\u003eAotearoa New Zealand (AoNZ)\u003c/p\u003e \u003cp\u003ePost-traumatic osteoarthritis (PTOA)\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Auckland University of Technology Ethics Committee granted ethics approval (Approval number: 22/257). All participants gave written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDaniel W. O\u0026rsquo;Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis have approved the manuscript and consent to publication.\u003c/p\u003e\n\u003ch2\u003eClinical trials number\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eAuthor contribution declaration\u003c/h2\u003e\n\u003cp\u003eDaniel W. O\u0026rsquo;Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis participated in the literature review, development of the research proposal, development of the participant interview schedule, data analysis, and manuscript preparation.\u003c/p\u003e\n\u003cp\u003eDaniel O\u0026rsquo;Brien and Josie L. Timmins also participated in ethics application, data collection, and transcription.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eArthritis New Zealand funded this research.\u003c/p\u003e\n\u003cp\u003eThe funding body had no role in the study\u0026apos;s design, data collection, analysis, interpretation, or manuscript writing.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eDaniel W. O\u0026rsquo;Brien, Josie L. Timmins, Tammi Wilson, Jackie L. Whittaker, Duncan Reid, Martin Rabey, and Richard Ellis participated in the literature review, development of the research proposal, development of the participant interview schedule, data analysis, and manuscript preparation.Daniel O\u0026rsquo;Brien and Josie L. Timmins also participated in ethics application, data collection, and transcription.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe dataset used and analysed during the current study is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFilbay SR, Skou ST, Bullock GS, Le CY, R\u0026auml;is\u0026auml;nen AM, Toomey C, et al. 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. Br J Sports Med. 2022;56(24):1465\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarkey MS, Baez S, Lewis J, Grindstaff TL, Hart J, Driban JB, et al. 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J Am Coll Radiol. 2018;15(1, Part B):149\u0026thinsp;\u0026ndash;\u0026thinsp;52.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anterior cruciate ligament, Knee, Management, Osteoarthritis, Physiotherapy, Post-traumatic, Rehabilitation, Aotearoa New Zealand","lastPublishedDoi":"10.21203/rs.3.rs-8370277/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8370277/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnterior Cruciate Ligament (ACL) injury and subsequent ACL reconstruction (ACLR) have a significant health impact in Aotearoa New Zealand (AoNZ). These injuries frequently lead to the development of post-traumatic osteoarthritis (PTOA) and can considerably disrupt the lives of typically young, active individuals, often requiring lengthy rehabilitation and effecting overall well-being. This study aimed to gain insights from health professionals and the communities caring for people with PTOA following ACL injury in the medium- to long-term in AoNZ to inform more effective and contextually appropriate approaches to management and well-being for this patient group.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eA qualitative Interpretive Description study was employed. Semi-structured individual interviews gained insights from end-users who could speak to the management of people with PTOA following ACL injury. Data were thematically analysed.\u003c/p\u003e\u003ch2\u003eFindings:\u003c/h2\u003e \u003cp\u003e16 participant end-users including health professionals, sports coaches, whānau (family), and policy makers were interviewed. Four themes were developed from the data: 1) Knee for life: Supporting the whole journey (recognising the long-term consequences of PTOA that can be neglected in the health system), 2) Care beyond the clinic (community engagement and a collaborative effort is required to provide long-term holistic care), 3) The blame game (financial and hierarchical conflicts surround ACL and PTOA rehabilitation, where limited accident insurance funding, and a reluctance of external services to accept responsibility impede outcomes), and 4) Shifting the goal posts: Beyond athletes and sport (a prominence of sport and athlete models of care dominate ACL management, where care and successful outcomes should extend beyond the physical aspects and more closely reflect holistic measures and patients' personal goals).\u003c/p\u003e\u003ch2\u003eConclusion and Impact:\u003c/h2\u003e \u003cp\u003eACL injuries should be viewed as a lifelong evolving journey rather than self-limiting isolated events. Clinically, adopting a multidisciplinary, patient-centred approach is critical. Early and sustained patient education on long-term knee health, lifestyle adaptation, and involving whānau in rehabilitation are essential. Transitioning from an injury-focused model to a holistic, sustainable support approach can significantly enhance long-term outcomes after an ACL injury and development of PTOA. Future research should prioritise developing and evaluating integrated, context-specific care models specific to the AoNZ context.\u003c/p\u003e","manuscriptTitle":"Exploring the support environment for people following anterior cruciate ligament injury in Aotearoa New Zealand","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 08:31:44","doi":"10.21203/rs.3.rs-8370277/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"137080933331208355289210623416909362876","date":"2026-01-18T12:01:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-16T09:42:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-19T11:38:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-17T06:11:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T06:09:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-12-15T22:45:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"671736a0-5ac9-499f-b987-ed52238250a9","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T08:31:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 08:31:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8370277","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8370277","identity":"rs-8370277","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}