One of the most devastating injuries in sports is tearing of the anterior cruciate ligament, or ACL. For starters, it’s probably the most fear-inducing injury.
Why such a Terror?
There are various reasons for it:
- It is commonly perceived and accepted that a torn ACL punches your ticket for reconstruction surgery, and brings with it 4-9+ months of rehabilitation and generally means missing a whole season.
- Current research shows that, for those athletes who sustain an ACL injury, about 60% of these athletes make a full recovery, less than 60% return to sport, and more than 50% develop knee osteoarthritis (most commonly though these individuals also have meniscus injury which seems to be highly predictive of osteoarthritis development).
- Increasingly, the rate of re-injury has become a significant concern for athletes seeking to resume their prior activity level after an ACL surgery. AJSM in 2016 concluded athletes younger than 25 years who return to the sport has a second ACL injury of 23%. Also, Webster et al. studied that the graft ruptures occurred in 18% patient at an average of 1.8 years after surgery and almost 47% occurred in the first postoperative year, while 74% occurred within the first 2 years following surgery
SO, once the patient/athlete comes for ACL rehabilitation, the one and only question they have is
“When can I get back to my Sports and start playing regularly?”
You will be tempted to give them a warm answer or an answer what they want to listen. But take my word and DONT.
In order to predict SAFE and SUCCESSFUL Return To Sport (RTS), there are recent researches helping to make a decision based on meeting key performance criteria, rather than allowing the player to RTS based on time-frame, alone, or getting cleared to play from the orthopedic surgeon based on the series of static clinical test.
What are those Key Performance Criteria?
There are two solid types of researchand guiding you to determine an athlete’s or patient’s readiness to RTS after ACL rehab. The criteria are:
- Quads strength: no more than 10% difference between sides
- 4 single leg hop tests: no more than 10% difference between limbs
- T-Test agility drill performed in under 11 seconds.
- Also, one study mentioned, abnormal hamstring to quad ratio was found during testing that was a contributing factor to future ACL injury. This testing was performed on a laboratory machine (isokinetic) which is difficult to translate clinically. For those who have access to hand-held dynamometry; As a general rule the player should also have a Quad: Hamstring ratio of <1.5:1 before RTS.
- Educate the patients and athletes that they can return to training and RTS with a reduced risk of ACL re-injury, anytime after the 9-month mark. However, before they even contemplate stepping on to the field for a competitive game, they should also be cleared clinically by their orthopedic surgeon and they absolutely must meet ALL the above key RTS criteria.
- Also, the key performance criteria should be tested in a fatigued state at the end of a training session, as it is well established that fatigue has been shown to be a contributing factor to ACL injury. Remember, we need to be training and testing our players for the worst-case scenario of their sport, not just the average demands.
- Wiggins AJ, Grandhi RK, Schneider DK, Stanfield D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul;44(7):1861-76.
- Webster KE, Feller JA.Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2016 Nov;44(11):2827-2832.
- Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA.Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016 Jul:50(13):804-8. doi: 10.1136/bjsports-2016-096031.
- Kyritsis P, Bahr R, Landreau P, Miladi R, Witnrouw E.Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med.2016 Aug;50(15):946-51. doi: 10.1136/bjsports-2015-095908. Epub 2016 May 23.
Dr. Mansi PArikh
Co-Founder EndoRush App