Sports Medicine Research: In the Lab & In the Field: Return to Sport Following ACL Reconstruction Surgery - How Many Athletes Return to Preinjury Levels? (Sports Med Res)


Wednesday, February 8, 2012

Return to Sport Following ACL Reconstruction Surgery - How Many Athletes Return to Preinjury Levels?

Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play

Ardern CL, Webster KE, Taylor NF, & Felller JA. British Journal of Sports Medicine. 2011;45: 596-606. 

Anterior cruciate ligament (ACL) reconstruction is often performed in an effort for an athlete to return to sporting activity.  General outcomes are successful, but it remains unclear how many people return to play and participate at their preinjury levels.  This study was a systematic review with the purpose to determine return-to-sport outcomes (e.g., return to participation at preinjury levels) after ACL surgery.  Forty-eight studies that evaluated return to sport in 5770 participants were included in the review.  Average follow-up time was 41.5 (range 12 to 85) months and the mean age at follow up was 25.1 (range 13 to 60) years of age.  Patellar tendon autograft was used 69% of the time and 20% had hamstring tendon autografts.  Eighty two percent of the participants had returned to sport at follow-up, and only 63% reported to be at preinjury level of participation in sport.   A quality assessment revealed that 19 studies inadequately described the participant population, 18 inadequately reported preinjury participation level, and 18 failed to report number of participants returning to preinjury level of participation.

As clinicians, we are aware that outcomes following ACL reconstruction are favorable for return to normal function.  However, outcomes for returning to a preinjury level of participation do not seem as favorable.   What is interesting is that in this review, only 44% of the participants returned to competitive sports, while 82% returned to some sporting activity.  The remaining 18% never return to a sporting activity.  Biomechanics have been demonstrated to be returned to almost normal; however this may not be the only factor.  Approximately 90% of the participants reported normal knee function outcomes, yet identified other non-biomechanical factors (e.g., fear of reinjury, lifestyle changes, fear of job loss) as to why participants did not return to play. These non-biomechanical factors may be a result of psychosocial factors or neuromuscular deficits.  Our clinical evaluation tools for return to play criteria are limited in ability to determine preparation in either of these areas.  Strength and function may appear normal, but rehabilitation needs to be all encompassing to appropriately prepare an athlete for return to play at preinjury levels.  Has anyone had any success stories of how they appropriately addressed all areas for an athlete to be adequately prepared for return to play?  Also, in a seemingly abundant area of research, few studies met appropriate quality assessment criteria for generalizations to be made.  We still need to improve the ACL research that is being conducted by gathering and reporting the appropriate information.  Furthermore, the average follow up time was less than 4 years.  For successful outcomes to be deemed, ACL reconstruction outcomes need to be investigated longer term as well.  Do you think that we should continue to focus on restoration of biomechanics, or are there other areas that you think need to be addressed in ACL reconstruction rehabilitation programs?    

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:

Ardern CL, Webster KE, Taylor NF, & Feller JA (2011). Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. British Journal of Sports Medicine, 45 (7), 596-606 PMID: 21398310


Theresa Bowers PT said...

Some of the reasons for not returning to "competitive" sports is simply timing. If a high school athlete has an ACL reconstruction late in their junior year, or in their senior year, they do not return to "competitive sports" unless they were committed to playing in college. If a college athlete has reconstruction late junior year or senior year, their window of opportunity to play competitive sports has closed (for most sports). This may skew the followup data.

Jeffrey Driban said...

Theresa that's a great point. The average age among the studies we ~25 years and the average follow-up was almost 3.5 years which would make this very pertinent. The more important question may be are the athletes returning to the level of competition that they were hoping. I don't think that question has been well addressed.

I think based on the quality of life (QOL) research after ACL reconstructions it would seem that either these athletes are not returning to the level of function they were hoping for, post-traumatic changes are contributing to diminished QOL, or other factors may be contributing. I'm not suggesting that the QOL data definitely indicates that athletes are not meeting the expectations they set (that's probably to far of a stretch) but rather this data in conjunction with the current study seems to indicate this area requires further study.

For example:

Nicole Cattano said...
This comment has been removed by the author.
Nicole Cattano said...

Theresa's point is extremely valid. But an alarming 18% never returned to any sporting activity-competitive or not. Most high school athletes continue some type of recreational sporting activities through college/adulthood.

To Jeff's point, the more important question is for those that DO return to sporting participation, are they returning to pre-injury levels of competition when they intend to. These authors had reported that for those studies that collected this information, only 62% had reported returning to pre-injury levels. These seems concerning to me, and warrants further investigation as to why this may be. Is is biomechanical, nueromuscular, psychological, or psychosocial in nature? There are a plethora of possible culprits. Furthermore, pre-injury levels of competition may be an entirely different outcome than how the athlete felt/performed in activities pre-injury.

abegail Casidsid said...

Undergoing an ACL reconstruction surgery is not easy, because it is major surgery. It is elective surgery; meaning that the patient, in consultation with the surgeon, decides whether or not to proceed with the operation. As with any other surgery there are risks and benefits.Benefits such as: Prevent further tissue damage to the ACL, Help to prevent early onset arthritis, Provide relief from intense pain and swelling, and With the outpatient procedure there is less scarring and faster recovery. But there are also some risk on undergoing an ACL Surgery such as: Lengthy recovery time – six to nine months, Rehabilitation therapy is intensive and can be painful, Costs may not be covered by insurance or Procedure not suitable for young people who are still growing.
Each patient must weigh the benefits and disadvantages for him/herself. For many, the promise of enhanced quality of life outweighs the disadvantages.

To know more about How is ACL Reconstruction Surgery Performed? visit

Anonymous said...

thanks for sharing.

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