Return to sport specific performance after primary anterior
cruciate ligament reconstruction: a systematic review
Mohtadi N
and Chan D. Am J Sports Med. [Epub
Ahead of Print]. 2017
Take Home Message: Elite level athletes who undergo anterior cruciate
ligament (ACL) reconstruction return to sport with little or no decrease in
Anterior cruciate
ligament surgery is often performed with the aim of restoring joint
biomechanics and allowing an athlete to return to participation with no
limitations. Return to pre-injury levels of sports participation varies among
groups. A better understanding of how different groups of athletes cope with
the injury and subsequent ACL reconstruction would allow clinicians to tailor
their education and stratify treatment protocols to provide the greatest
benefit to an athlete. Therefore, Mohtadi and Chan completed a systematic
review to identify sport-specific performance outcomes after ACL
reconstruction. Secondarily, the researchers sought to identify any risk of
bias in the published literature. Following a comprehensive literature search
according to the PROSPERO International Prospective Register of Systematic Reviews, the authors included 15 articles in
the systematic review. All studies were case series or cohort studies that
measured sports-specific performance among individuals after an ACL
reconstruction. The included studies involved athletes participating in soccer,
football, ice hockey, basketball, skiing and snowboarding, and baseball. While
not a criterion for inclusion, all athletes competed at an elite level (NCAA
division one seeking a professional career, or professional athletes).
Following data extraction, the authors evaluated the risk of bias of each study
using the Quality in Prognosis Studies (QUIPS) tool.
Overall, the authors found high return-to-sports rates ranging from 63% (football)
to 97% (ice hockey). Most studies indicated a decline or no change in
performance (e.g., less games played, less scoring) following an ACL
reconstruction. Only 3 of the 15 studies (football and skiing/snowboarding)
reported higher performance after an ACL reconstruction. In studies with a
control group, the control group had better performance than the athletes with
an ACL reconstruction. The secondary QUIPS analysis identified that all studies
had some risk of bias. Twelve studies had a high risk of bias, two had medium
risk, and only one had a low risk of bias.
Overall, the results of
the systematic review are interesting for all clinicians, but particularly
clinicians who treat elite-level athletes. Generally, an elite athlete had little
or no declines in performance after ACL reconstruction. Overall, this agrees with
other similar studies. However, given this population, there is an additional concern
that even a small decrease in performance could negatively impact both an
athlete and a team. If an elite athlete experiences a small decline in performance,
then it could impact their salary and ability to remain competitive at an elite
level. While the authors didn’t look at the potential impact of these declines
in performance, it should be considered by clinicians who are helping guide these
athletes through an injury and recovery process. Future research could benefit
from looking not only at elite level athletes but also at lower level athletes (high
school, collegiate). Furthermore, the lack of studies evaluating collegiate and
high school athletes presents an opportunity for future research which can be
more widely applied to daily practice. Until more studies can be completed,
clinicians should add the results of this study to the ever-expanding library
of knowledge concerning outcomes after an ACL reconstruction. It is important
to discuss results like these (and areas where we just don’t have information)
with our athletes so that an athlete can have proper expectations about their post-operative
Questions for Discussion: Do the results of this study align with what
you have experienced in your clinical practice? 
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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