of ACL graft rupture: not meeting six clinical discharge criteria before return
to sport is associated with a four times greater risk of rupture

P, Bahr R, Landreau P, Miladi R, & Witvrouw E.  Br J Sp
. 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.

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.

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?

by: Nicole Cattano
by: Jeffrey Driban


Graft Type May Influence ACL Reinjury Rates

Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., & Witvrouw, E. (2016). 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 British Journal of Sports Medicine DOI: 10.1136/bjsports-2015-095908