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What criteria should patients meet before returning to pivoting sports after ACL surgery?
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Click here to read the Cover Story, “Patients who never make it back after ACL injury present opportunities, challenges.”
Succeed in evaluation program
There is increasing evidence athletes do not return to the same level of play for up to 2 years postoperatively. Additionally, many centers are now advocating formal testing before allowing athletes to return to play. The testing includes isokinetic strength evaluation, functional activities (one-legged hop, etc.), jump/landing evaluation and sports-specific activities. At the University of Virginia, all ACL-reconstructed patients who want to return to sports are referred for a lower extremity assessment protocol. The program includes isokinetic quadriceps and hamstring strength testing and evaluations of muscle endurance, balance, jump testing and patient-reported outcomes. Our benchmark for patients is 90% or greater symmetry on these tests prior to re-integration to pre-injury level of activity or sports. In our testing program, we have found it is highly unusual for an athlete to successfully pass the tests (typically 85% performance) at 5 months to 6 months following ACL reconstruction and their quadriceps strength and jumping performance can be profoundly impaired — sometimes reaching 60% of the opposite side despite patients perceiving they are ready to return to unrestricted physical activity.
Our evaluation program guides rehabilitation and return-to-sport decisions. Patients often return for re-evaluations, especially in the first 2 years after reconstruction, as this is the time when reinjury risk is highest. Patients may benefit from annual re-evaluations because it is well known that muscle strength often deteriorates in the years and decades after ACL reconstruction and muscle weakness may interfere with the patients’ ability to engage in physical activity.
Mark D. Miller, MD, is S. Ward Casscells professor and head of the Division of Sports Medicine in the Department of Orthopaedic Surgery at the University of Virginia. Joe Hart, PhD, ATC, is an associate professor of kinesiology and director of clinical research of orthopedic surgery at the University of Virginia.
Disclosures: Miller and Hart report no relevant financial disclosures.
Criteria for return to sport
Another way to ask this question is, “How do we judge successful outcomes following ACL reconstruction?” My friend and first vice president of International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, Willem Mare van der Merwe, MBChB, FCS, SA (Ortho), from South Africa, once explained ACL outcomes at the Panther Global Summit in Pittsburgh, saying, “Return to sport (RTS) and protection of the knee from post-traumatic osteoarthritis are two conflicting outcomes of ACL reconstruction.” With that in mind, our goal must be to ensure a safety first-approach. However, athletes and workers often are interested in timelines rather than meeting criteria, specifically returning as soon as possible.
I believe RTS should be criteria-based. We should investigate how the ACL is healing. This can be done, for example, using MRI scores for graft maturity, as shown by my chairman and mentor, Freddie H. Fu, MD, DSc(Hon), DPs(Hon). Other common criteria have to do with function of the musculoskeletal system, the quadriceps hamstring index, hip/core strength and balance and prevention of valgus collapse. A study from the Swedish ACL Register by J. Karlsson and colleagues in Gothenburg, Sweden, showed patients who successfully returned to sport had better subjective knee function and higher self-efficacy of knee function. Therefore, physicians involved in ACL surgery and rehabilitation should pay special attention to psychological factors in RTS, as well.
In Pittsburgh, we employ sport-readiness tests, such as those described by Lynn Snyder-Mackler, PT, ATC, ScD, SCS, FAPTA. A good time for a sport-readiness test is about 6 months to 8 months postoperatively. If used correctly, it can point out certain deficiencies that can be focused on prior to a structured return to play. Once return to play is started, there should be a stepwise increase in activity, ideally from non-contact practice to contact practice; short playing time on the B team; more playing time and eventually return to the first team and full match play. For more information on this topic, a new European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA) book, “Return to play in football: An evidence-based approach,” will be available before the ESSKA Congress in May 2018 in Glasgow.
- References:
- Eitzen I, et al. Knee Surg Sports Traumatol Arthrsc. 2010;doi:10.1007/s00167-010-1113-5.
- Ma Y, et al. Knee Surg Sports Traumatol Arthrosc. 2015;doi:10.1007/s00167-014-3302-0.
- Senorski EH, et al. Knee Surg Sports Traumatol Arthrosc. 2017;doi:10.1007/s00167-016-4280-1.
Volker Musahl, MD, is medical director at the University of Pittsburgh Medical Center Rooney Sports Complex, program director of the Sports Medicine Fellowship at the University of Pittsburgh and associate professor of orthopedic surgery and bioengineering at the University of Pittsburgh Medical Center for Sports Medicine.
Disclosure: Musahl reports no relevant financial disclosures.