Sports Medicine Research: In the Lab & In the Field: We Are (Not Helping) the Youth of Our ACL Nation (Sports Med Res)


Wednesday, November 8, 2017

We Are (Not Helping) the Youth of Our ACL Nation

Young Athletes After Anterior Cruciate Ligament Reconstruction Cleared for Sports Participation: How Many Actually Meet Recommended Return-to-Sport Criteria Cutoffs?

Toole AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, & Schmitt LC. J Orthop Sports Phys Ther. 2017; Online Ahead of Print October 26, 2017.  

Take Home Message: Most athletes are NOT meeting accepted clinical cutoffs for strength and functional testing prior to returning to sport after an ACL reconstruction.

It is recommended that clinicians use objective criteria to make return-to-play decisions for patients after an anterior cruciate ligament (ACL) reconstruction. It remains unclear how many athletes who are cleared to play meet suggested criteria and if those who meet the criteria are more successful in returning to pre-injury levels of activity.  Therefore, the authors investigated the proportion of athletes who met predefined criteria for strength, hop testing, and patient-reported outcomes and whether meeting the criteria made an athlete more likely to maintain their pre-injury level of physical activity/sport participation.  The criteria were an International Knee Documentation Committee subjective form (IKDC) score > 90, quadriceps and hamstring strength limb-symmetry indices > 90%, or single-leg hop test symmetry > 90%, or a combination of these criteria. The researchers assessed the above criteria in 115 young athletes within 4 weeks of return-to-sport clearance, and then reassessed their activity levels one year later.  Just over half of the athletes met all hop testing criteria, and less than half met the criteria for the patient-reported outcome.  Furthermore, just under 30% met the criteria for their quadriceps and hamstrings strength, and only 14% met all criteria.  About 66% of athletes maintained their physical activity one year later, and this was more common among those that met both strength criteria (81%) compared with those who did not meet both (60%).  Interestingly, no differences were found for physical activity level for those who met all criteria, hop tests, or individual criterion.

The authors demonstrate that an athlete is more likely to maintain physical activity levels one year after returning to play when they meet return-to-sport criteria based on strength, and that an alarming number of athletes are not achieving this criteria prior to returning to play. This finding shows that we should emphasize strength indices.  The other symmetry measures and patient-reported outcome criteria were less effective at differentiating which athletes would continue at the same activity level at one year after returning to play. This may be because 1) other factors can influence a person’s physical activity (e.g., graduating from school, other life commitments), 2) these measures at the time of return to play are not as informative as changes in them over the next year, or 3) these measurements fail to accurately reflect the state of a patient. It would have been informative to see how these measures changed over time and if they predicted who would experience increases in joint symptoms or new injuries.  Patient-reported outcomes have been reported in previous posts to be good at differentiating readiness for functional testing. Clinicians need to do a better job using standardized strength cut-offs because they seem to be linked with a higher likelihood of success in physical activity levels, in addition to assessing their psychological readiness. The fact that less than 1 in 3 athletes met the strength criteria is alarming and shows a need for us to slow down and think about what is beneficial to the athlete in the relative short term (return to sport) as well as even longer term (20 years later).      

Questions for Discussion:  What criteria are you utilizing for return to sport after an ACL reconstruction? 

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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