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
Kyritsis P, Bahr R, Landreau P, Miladi R, & Witvrouw E. Br J Sp Med. Published Online First: May 23, 2016. doi: 10.1136/bjsports-2015-095908
Take Home Message: Patients should attain all objective criteria goals prior to returning to sport. A professional athlete who fails to meet functional criteria for return-to-sport or who has a low hamstring:quadriceps ratio is at greater risk for an anterior cruciate ligament graft rupture.
Athletes and clinicians are often focused on how quickly can we return a patient to sport after an anterior cruciate ligament (ACL) rupture. There is no “set” return-to-play parameters that need to be met, and oftentimes clinicians think an athlete is “close enough” or will regain the remaining deficits upon return to sport. However, history of an ACL injury is one of the largest risk factors for sustaining another ACL injury. Hence, the authors conducted a prospective cohort study to evaluate whether certain return-to-play criteria (e.g., functional assessments) were associated with risk of an ACL graft rupture after return to sport. The authors followed 158 male professional athletes after ACL reconstruction, who returned to sport on average 229 days after injury (range 116-513 days). Prior to the athlete returning to sport, the authors assessed concentric isokinetic quadriceps and hamstring strength and functional performance (i.e., agility t test, single, triple, and crossover hop tests). Twenty-six athletes suffered graft ruptures, while 11 suffered contralateral ACL ruptures. Over 60% of the graft ruptures occurred within the first 6 months after return to sport. An increased graft rupture risk was identified in athletes who did not attain all 6 discharge criteria or who had decreased hamstring-to-quadriceps ratios. Over half of the graft ruptures occurred in patients who were not fully discharged by their surgeon.
The findings of this study are interesting because these authors show that an objective set of return-to-sport criteria may be associated with ACL injury risk after an ACL reconstruction. However, it would be interesting to know whether or not the lack of meeting certain criteria was driven by patient qualities. For example, motivation, fear, and compliance factors may differ between those who met the return-to-play criteria or not. The authors note that early return to sport may be linked to an increased risk of ACL graft rupture because the graft ruptures tended to occur relatively early after injury in relationship to return to sport. Interestingly, this is one of the first research projects to prospectively evaluate the role of the hamstrings in possibly protecting the graft upon return to sport. These authors collected graft type, but it would be worth investigating further to see if graft site was affiliated with strength changes. Ultimately, as clinicians we should focus more on the successful attainment of objective criteria rather than getting patients to “as good as we can get,” because we may be setting the patient up for failure.
Questions for Discussion: What are some criteria that you utilize when making your return to sport decisions for athletes after an ACL injury? Are their certain tips or tricks that you like to utilize when an athlete cannot seem to get stronger or perform better on a certain task?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban
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