Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction

Barber-Westin SD and Noyes FR. Arthroscopy. 2011;27(12):1697-1705.

Anterior Cruciate Ligament (ACL) injury occurs frequently in the US in young athletic individuals under the age of 25. Reconstruction of this ligament is frequently done with the intention of returning to playing sports. However, the rates of re-injury of the reconstructed ACL range from 4.3 to 19% and up to 24% in the contralateral knee. Limited research on an effective rehabilitation program after ACL reconstruction has been completed and there is no consensus on appropriate criteria to allow athletes to return to play. Therefore the purpose of this systematic review was to evaluate current factors that are being used to determine return to unrestricted play after surgery. Studies were included in this analysis if they had a minimum of 12 month follow-up, subjects were skeletally mature and this was the primary ACL reconstruction of any graft type (revisions were excluded). Both contact and non-contact injuries were included in this analysis. A literature search identified 264 studies that evaluated ACL reconstruction, however only 159 of these studies reported criteria for return to sport. The different criteria used in these studies included time after surgery, muscle strength, knee examination of effusion and range of motion (ROM) measures, single leg hop test measures, knee stability with a Lachman Test and measures from validated questionnaires. Of these studies, 60% included time after surgery to be a criterion for return to sport and only 32% used time after surgery as the only criterion. Differences in graft type had no effect on return to sport time point. Nine percent of studies reported muscle strength criteria. Eighty to ninety percent isokinetic strength measures of quadriceps and hamstrings compared to the uninjured limb were required. Three studies reported thigh circumference measures of 1cm difference between limbs as a requirement for return to sport. Six percent of studies required minimal to no effusion and/or full ROM measures as a return to sport criteria. Single leg hop measures of ≥ 90% symmetry between limbs was a requirement for return to sport in 4% of studies. Only 1 study required ≥ 90% for all 4 hop measures. This study by Hartigan et al also used validated questionnaires as criteria for return to sport. A ≥ 90% score on the KOS-ADLs and the global rating scare was required for return to sport. Objective knee stability measures using the Lachman Test was reported as criteria in only 1 study.  

Based on these results, there is a wide variety and lack of standardization of return to sport criteria. Time after surgery appears to be the most commonly used criteria and often the only criteria for clearance of return to sport. Of this entire review only 2 studies (Hartigan et al, Mascarenhas et al) required 3 to 4 objective measures, not including time after surgery. Both studies measured quadriceps strength, hop test measures, required full ROM and minimal effusion. Less than 10% deficit compared to the uninjured limb is required to pass these return to sport criteria. Paterno et al identified asymmetrical movement patterns that were predictive of subsequent ACL re-injury. High re-injury rates support these data that there is lack of standardization of return to sport criteria. Attention to measures of symmetry between limbs may be an important component that we are missing when determining the appropriate return to sport criteria. What criteria do you use with your ACL reconstructed athletes for clearance of return to sport? Do you think we should use more objective measures besides time after surgery?

Written By: Kathleen White
Reviewed By:  Stephen Thomas

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Barber-Westin SD, & Noyes FR (2011). Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy, 27 (12), 1697-705 PMID: 22137326