Current return-to-sport criteria may not identify second ACL injury risk for youth athletes

ByKristine Houck, MA, ELS

SAN DIEGO – Current criteria that evaluate the readiness of youth athletes to return to pivoting and cutting sports after ACL injury may not identify the athletes who are at high risk for second ACL injury, according to data presented at the American Orthopaedic Society for Sports Medicine Annual Meeting.

Perspective from Gehron Treme, MD

Mark V. Paterno

“Young pivoting/cutting athletes who were able to meet the six return-to-sport criteria did not appear to be less likely to suffer an ACL injury, suggesting that other factors such as quality of movement or psychological readiness may need to be added to current return-to-sport criteria to better identify athletes ready to safely return to sport,” Mark V. Paterno, PhD, PT, said in his presentation here.

In the prospective, observational cohort study, Paterno and colleagues studied 159 patients who underwent primary, unilateral ACL reconstruction, performed rehabilitation and returned to a pivoting and cutting sport to observe if meeting all current, standard return-to-sport criteria identified the young athletes who were at risk for a second ACL injury. Patients were monitored for a second ACL injury for 24 months. The mean age of the cohort was 17.2 years and average time to return to sport was 7 months.

The return-to-sport assessment included isometric quadriceps strength test, four functional hop tests and the IKDC patient-reported outcome survey. Limb symmetry index was calculated for strength and hop test assessments. Researchers grouped the patients by who passed all six return-to-sport tests at a level of 90 and then at a level of 95, and then compared them to patients who failed to meet all six criteria.

At the time of return to sport, 26% of patients had limb symmetry index of greater than or equal to 90 on all testing as well as an IKDC value of 90 or greater. Paterno and colleagues found 16% of patients had a second injury within the first 12 months of return to sport and 22% of patients had a second injury within 24 months after return to sport. There was no difference in second injury rates when comparing patients who met all current return-to-sport criteria and patients who failed to meet all return-to-sport criteria at 90 and 95 levels.

“In populations of young active, pivoting/cutting athletes, their ability to successfully achieve return to sport criterion at either 90 or 95 criterion level were not able to identify athletes who were at lower risk for future ACL injury,” he said. – by Kristine Houck, MA, ELS

Reference:

Paterno MV, et al. Paper 103. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 5-8, 2018; San Diego.

Disclosure: Paterno reports no relevant financial disclosures.

Perspective

Gehron Treme, MD

Paterno and colleagues are congratulated on their efforts in further clarifying our understanding of return-to-sport (RTS) criteria after ACL reconstruction. In this study, the authors take on arguably the most demanding group of ACL reconstruction patients — the young, pivoting sport athlete — and shed light on our ability to assess when these patients are appropriate for RTS. Criteria used included previously validated measures including IKDC, hop testing and strength testing assessments. Unlike in some other studies in which these assessments have been shown to predict greater risk of a second ACL tear, the subjects studied here showed no difference with respect to their second injury rate regardless of whether they achieved the established threshold to pass each of these tests.

While the differences in the literature and the findings of this study may be multifactorial, a large contribution likely comes from the focus on this high-risk group. It may be that the risk incurred by this group of athletes for a second ACL injury is so great that more refined methods of evaluation should be entertained such as movement mapping and psychological measurements along with our standard assessments. Surprisingly, only 26% of participants in this study achieved the goal 90% passing on the tests which raises further questions about the usefulness of these tests in this group. As the authors state, there is much work to be done as we attempt to increase the number of athletes well prepared to re-enter pivoting sports and by extension decrease their risk for additional knee injuries after their return.

Gehron Treme, MD

Associate professor and residency program director

UNM Orthopaedic Surgery

Albuquerque, New Mexico

Disclosures: Treme reports no relevant financial disclosures.