of Early Functional Recovery After ACL Reconstruction: Functional Milestone
Achievement and Self-Reported Function

MC, Sikka RS, Tompkins M, Nelson BJ, & Chmielewski TL.  Sports
2018 10(4): 345-354. DOI: 10.1177/1941738118779762
Take Home Message: After an
anterior cruciate ligament reconstruction, patients report significant
improvements during the first month after surgery. Many important milestones
often occur during the first 15 days after surgery (e.g., return to school,
work, driving). Higher age, male sex, allograft selection, and lower body mass
index (BMI) are associated with achieving functional milestones earlier than
their peers.
Anterior cruciate ligament (ACL) injuries
and decisions to have these surgically repaired are common among physically
active Americans.  While we often focus
on the medium- to long-term outcomes after an ACL reconstruction (e.g., return
to sport), early functional recovery is also important.  If clinicians knew early functional milestones
then it could help patients set realistic expectations and provide them
feedback on progress, which may improve a patient’s experience and treatment
adherence.  These authors prospectively
followed 182 participants who had primary ACL reconstruction to determine the
time to early functional milestones over the first 12 weeks after an ACL
reconstruction. They also sought to determine patient characteristics that may
be related to early functional outcomes. The authors selected participants without
concomitant complicated procedures (i.e., meniscus repair, microfracture,
multi-ligament reconstruction) and assessed them prior to and at 1, 2, 4, 8,
and 12 weeks post-surgery.  The researchers
focused on self-reported functional milestones such as medication
discontinuation; progression to non-assisted ambulatory status; and return to
work, school, or driving. The authors also assessed self-reported function as
scored by the Short Musculoskeletal Functional Assessment questionnaire. 
Participants showed functional improvements over the 12 weeks
post-surgery, with the greatest improvements during the first month after surgery.
The median times to functional milestones are described below. No demographic
predictors were not found to be associated with self-reported function scores
changes over time. 

Functional Milestone
Median Time to Milestone
(day by which half the people met it)
Factors related  to achieving the milestone earlier
Return to school
7 days
Discontinue pain medications
9 days
Return to work
11 days
Higher age, males, lower BMI,
light occupational demands
Return to driving
11 days
Higher age, males, left knee
Discontinue crutches
15 days
These researchers followed patients
longitudinally after an ACL reconstruction and linked certain predictors to
short-term functional milestone achievements. 
This study is a good addition to the field because it gives us an idea
of timeframes to achieve functional milestones, as well as the modifiable and
nonmodifiable factors that may be linked to these achievements.  It was interesting, yet not surprising, to
see that allograft reconstructed patients tended to discontinue their pain
medication use faster than autograft patients. 
As a clinician, these results may help us educate our patients on what
to expect based on their graft selection. 
It would be interesting to continue to follow these patients out longer
to see if their graft selection caused any different long-term outcomes (e.g.,
failure rates, osteoarthritis), as many researchers have investigated these
differences.  The fact that higher age
was a predictor of return to work and drive was fascinating to me.  We often think that our younger patients tend
to be more resilient, so I wonder if there were other factors such as the
inability to miss work or other societal demands that incentivized this faster
return compared with younger patients. 
But, we need to ask ourselves whether a faster return is necessarily
better.  Ultimately, continuing to follow
these patients over time to determine their self-reported function, as well as
their clinical outcomes (such as, strength, limb symmetries, and possible
clearance) would help clarify the long-term benefits or consequences of meeting
these milestones faster.  Clinically, we
can use this information to educate our patients and help ourselves recognize
what we might be able to control and expect post ACL reconstruction. 
Questions for Discussion:  What are
the relatively short-term functional outcomes that you are interested in seeing
in your patients?  Are there any other functional
outcomes that you might find interesting (perhaps past 12 weeks) in the
physically active population?
by: Nicole Cattano
by: Jeffrey Driban