Sports Medicine Research: In the Lab & In the Field: Not So Competitive Return Rates to Activity Following ACL Reconstruction (Sports Med Res)


Wednesday, September 17, 2014

Not So Competitive Return Rates to Activity Following ACL Reconstruction

Fifty-five percent return to competitive sports following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors

Ardern CL, Taylor NF, Feller JA, & Webster KE. Br J Sports Med.  Published online first August 25, 2014. doi: 10.1136/bjsports-2013-093398

Take Home Message:  Only 55% of athletes returned to competitive sport following anterior cruciate ligament (ACL) reconstruction.  The debate continues as to whether hamstring or patellar tendon autograft is better.  However, factors that may favor return to competitive sport include younger age, male gender, elite sport, and a positive psychological response.      

Return to sport participation following anterior cruciate ligament (ACL) reconstruction is often considered a measure of surgery success.  Unfortunately, we don’t have a good estimate of how often athletes successfully return to activity rates after an ACL reconstruction and which factors (individual and external) may affect return to activity.  Therefore, Ardern and colleagues conducted a meta-analysis to determine the return to sport rate after an ACL reconstruction and which factors favored returning to play. This meta-analysis included 69 articles and reported on 7556 participants with an average age of 26 years, 66% male, and 34% received a hamstring graft while 61% received a patellar tendon graft.  Eight one percent who had ACL surgery returned to any sport, 65% returned to their preinjury level of sport, and 55% returned to competitive level of sport.  Key factors that favored successful return to preinjury level of sport were being younger in age, male, an elite athlete, less fearful of reinjury, and of greater psychological readiness.  Graft selection continues to be inconclusive. Participants who received hamstring grafts had better odds of returning to any sport or competitive level sport, while participants who received patellar grafts had better odds of returning to preinjury levels of sport. The average follow-up was 40 months (range = 12 to 156 months) but the length of follow-up did not influence the return to play results.           
While there is a high rate of return to any sport (81%), the number of participants who return to preinjury or competitive levels of sport is relatively low.  There were some factors that favored successful return to preinjury levels; however, there are few that we can modify.  Important findings of this meta-analysis further emphasize that it would be advantageous for clinicians to dedicate time during the recovery process to address psychological readiness and fears of the participant.  The authors of this study updated an earlier study, which focused on research conducted before 2010, and showed that there was an increase in the return to competitive sport rate in this current study.  It is interesting to see that male elite athletes are more likely to return to competitive sport.  Future studies may benefit from determining timing of the participant’s knee injury.  For example, if an athlete suffers a knee injury at the end of their college career, there are very limited options for them to return to competitive sport.  Especially if an athlete is a female, there may not be as many options for them to continue to participate competitively.  A better understanding is needed of the athlete’s desired or attainable level of participation versus what they actually succeed in returning to.   The graft analysis results should be interpreted with caution as there were twice as many patellar tendon grafts as there were hamstring grafts.  Lastly, it would be very interesting to see this type of study replicated in younger aged groups (high school and college) as there are more opportunities for successful return to competitive sport.  However, I still caution clinicians to not look at return to competitive sport as the only criteria for success.  Following these participants into middle-aged and older adulthood would be very interesting to see if whether they returned to competitive level or not affected their risk for early osteoarthritis development.   

Questions for Discussion:  What do you think the younger aged population would look like in terms of return to competitive sport?  Are there any strategies that you utilize during your rehabilitation process to address fear of reinjury and psychological readiness?
Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

Related Posts:
Return to High School- and College-Level Football After Anterior Cruciate Ligament Reconstruction

Ardern, C., Taylor, N., Feller, J., & Webster, K. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors British Journal of Sports Medicine DOI: 10.1136/bjsports-2013-093398


sanky sanny said...

Why isn't anyone considering allograft during the ACL reconstruction? Is there any disadvantage towards allograft? If we are considering an autograft which is taking a hamstring/patellar tendon from our own body, will it weaken the leg? I know that it is safe to take the tendon from our own body so we can avoid any other type of infections. I believe that rehabilitation holds a big part in bringing the athlete back to his/her competiative level. This is an important article because i have a bunch of question about the advantages and disadvantages of having allograft and autograft.

Charmaze Banks said...

I know that ACL injuries are usually more common in females than males but surprisingly enough, this article focused more on the male population. Were there any particular reason why the return to sports of a female athlete after ACL reconstruction not discussed?

Rohan Ananthan said...

One of the key factors in successful return was psychological readiness/fear of re-injury. I'm wondering whether if different processes for psychologically preparation in a patient can play a role in the level of success. I think more studies need to be conducted to better understand the psychological side to returning to play. As stated in the article, the opportunities for successful return varied based on age, so to get a better idea of how desire and readiness help, the definition for successful return to play has to be altered. This will be able to incorporate non sport related successful return from a psychological perspective.

Rohan Ananthan said...

My biggest question how the patients were prepared psychologically to return? I'm assuming each was prepared differently, so I'm thinking more studies should be done to see what the most efficient way is to improve the psychological readiness. Also, I think that if each approach is individualized for the patient more success can be reached. Some may not have has high a desire because the opportunity for success is different in each case so it is important to understand that and have different goals to attain a successful return

Kari Romano said...

I would like to know why males were the ones to return to play? The way it was stated in the article made it seem like the study also looked at females, however there was no such evidence, as in percentages, that proved that this study looked at females. If there were females who participated in this study, I would like to know if they had similar rehabilitation to the male participants. If not, then maybe a future study would look at the differences, if any, in different rehabilitation for males and females with ACL reconstructions, to see if that effects return to play times.

Amber Lingham said...

This was a very interesting article; however what caught my attention the most was how come the research did not focus more on the psychological rehabilitation process of returning to play? I think this is an extremely important factor that would determine an athlete’s return to competitive play or pre injury play. Some athlete’s desire after reconstructive ACL surgery is just to come back and play while others are to come back better than before. Even though, patella tendon grafting and hamstring grafting surgeries does play a beneficial part in return to play in an ACL rehab process, I think the psychological readiness matters just as much.

Jeffrey Driban said...

Hi Sanky Sanny: Thanks for the comment. We have a reported on a meta-analysis that looked at the short- to mid-term outcomes after allografts or autografts: There's also this study:
There's not a lot of long-term data on this though and I'm not sure why. One study of note was

Restoration of function after a hamstring autograft tends to be good but there are people who don't make it back to their previous level of competition. It would be interesting to see how graft type influences strength and neuromuscular control among those who do or don't return to their previous level of competition. There's several studies that have been described on this site that look at symmetry, quad strength, hop performance at the time of return to play.

Charmaze and Kari: Thanks for the comment. Both genders were included in this meta-analysis. The authors found that males were more likely to return to competitive sport than females. Men were 1.5 times more likely than women to return to either their previous level of sport or competitive sport. I hope that clarifies that. Sorry for the misunderstanding. Nicole in her second paragraph explains some interesting things to consider when looking at these sex differences.

Rohan: I agree. It'll be very interesting to see more clinical trials testing psychological interventions as an adjunct to our current standard of care. It would appear we need to do more to prepare the athlete for return to play and improve their readiness and confidence in the knee.

Amber: Thanks for the comment. You're right that psychological readiness is important for return to play. We have several posts related to this on the site. There's not a lot of data though on how to intervene on these variables. I think this will be an area that gets some more attention in the future and it's long over due.

A question for everyone: Do you feel like you have adequate training to incorporate psychological components into your treatment strategy and if not do you have access to a sports psychologist who could help?

Jeffrey Driban said...

Thanks everyone for the great discussion!

Nicole Cattano said...

These are great comments/discussion! Psychologically - I think it is very important to address the entire athlete, but as clinicians, I think that personally I am focused on the athlete gaining confidence with tasks at hand for return to play. There are many athlete that I have chosen to refer to a sport psychologist.

The differences between men and women definitely warrant more investigation. There is a derth of literature surrounding long term outcomes in females. It may not be that the females could not physically return to activity, but perhaps that the opportunities for them to continue their sporting careers were very limited.

Great points!

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