ACL Injuries and Return To Play

The issue of return to play (sports) after ACL surgery has become a big issue and there are many recent papers on this topic. I want to use this to emphasize the importance of return to play decision making after any type of injury.

This excellent article by Mick Hughes called Return to Sport Following ACL Reconstruction in Young Athletes Mick Hughes makes some excellent points:

3 things that are critical to a successful RTS following ACL reconstruction:

1) Was the patient compliant to the ENTIRE rehab plan as set out by their physio, exercise physiologist or strength and conditioning coach?

2) Did the rehabilitation plan include a period of supervised jumping, landing, pivoting, unanticipated change of direction, unanticipated landing and sports specific conditioning?

3) Was the athlete cleared to RTS with strength tests and functional hop tests prior to stepping back on the field/court? And were these tests also passed in a fatigued state?

Let’s take a moment, back up and see why there is such confusion and such poor outcomes ….

1. Be careful when assessing surgical “success” rates. What does “success” really mean?

Anterior Cruciate Ligament Reconstruction—Not Exactly a One-Way Ticket Back to the Preinjury Level

when the level of participation was taken into account, it was found that only 65% returned to their preinjury level of sport and 55% returned to competitive sport. This means that 1 in 3 individuals did not return to his or her previous level of sports participation, and 1 in 2 did not return to competitive sport after surgery

PATIENT-SPECIFIC AND SURGERY-SPECIFIC FACTORS THAT AFFECT RETURN TO SPORT AFTER ACL RECONSTRUCTION

return to pre-injury level of sport is poor and re-injury rates are unacceptably high…. return to pre-injury level of sport is poor and re-injury rates are unacceptably high.

2. The medical world still uses time based return to play recommendations.

PATIENT-SPECIFIC AND SURGERY-SPECIFIC FACTORS THAT AFFECT RETURN TO SPORT AFTER ACL RECONSTRUCTION

Conventional clinical advice is for athletes to return pre-injury sports participation between four and six months post-operatively,2,3 however, time-based recommendations are based in theory and often do not accurately reflect patient capabilities.

Only 35 studies (13%) used objective criteria to determine RTS readiness.4 As this literature review shows, time after surgery is the most common criteria used to determine readiness to return to sport.

3. There are no established RTP criteria

PATIENT-SPECIFIC AND SURGERY-SPECIFIC FACTORS THAT AFFECT RETURN TO SPORT AFTER ACL RECONSTRUCTION

At present, no set of criterion based measures have been adequately studied to determine whether or not they are appropriate for ensuring successful return to sport with the smallest possible chance of re-injury or contralateral knee injury.

4. RTP Criteria

Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus

http://bjsm.bmj.com/content/50/24/1506#T6

Criteria for return to play:

- No knee pain at sport specific activities.

- No giving way or fear of giving way during sport specific activities.

- Active dynamic gait pattern, symmetrical jogging pattern143, and correct quality of

performance with all sport specific activities.

- LSI >90% for quadriceps and hamstring strength (to exclude quadriceps dominance and leg

dominance).51,158

- LSI >90% for a hop test battery51, with preference towards the hop test battery of

Gustavsson156, with the single-leg hop-and-hold test added (to exclude quadriceps dominance

and leg dominance).158

- Drop jump test with observation or video-analysis of the quality of movement, at least

measuring trunk lateroflexion, dynamic knee valgus (to exclude ligament dominance) and the

knee flexion angle when landing.

5. Lesson:

• Find a great therapist/trainer/coach

• Get all members of your RTP team on the same page. Yes, you will have to be your own captain

• Take your time and pay attention. You are the only one who really “knows” how you feel

• Don’t stop the “rehab.” All the strategies you used to RTP must be used going forward. This must become part of your “training”