Return
to High School- and College-Level Football After Anterior Cruciate Ligament
Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study
McCullough K, Phelps K,
Spinder K, Matava M, Dunn W, Parkers R, MOON Group and Reinke E. Am J Sports
Med. Aug 2012; [e-pub ahead of print]. 10.1177/0363546512456836
Spinder K, Matava M, Dunn W, Parkers R, MOON Group and Reinke E. Am J Sports
Med. Aug 2012; [e-pub ahead of print]. 10.1177/0363546512456836
Anterior cruciate ligament
(ACL) injuries are common among young football players. Surgical reconstruction
is currently the most common intervention to facilitate return to play, however
not all athletes are successful. Unfortunately, there is a lack of data
regarding how many football players return to play and what factors may
increase the risk of a player not being able to return to play. The purpose of
this study was to determine the percentage of high school and college-level football
players that returned to play at a minimum of 2 years after an ACL
reconstruction (ACLR) and the reasons why players did not return to play. All
patients were included in this study from the MOON
cohort if they reported football as one of the sports they participated in
since surgery or the sport they were playing at the time of their ACL injury.
These patients were interviewed regarding their return-to-play status,
advancement to the next level of competition, position played, performance
after surgery, and (if applicable) reasons for not returning to play. These
patients also completed the following validated questionnaires: International Knee Documentation
Committee (IKDC), Marx Activity Scale, Knee
injury and Osteoarthritis Outcomes Score (KOOS) sports and recreation subscore and quality of
life (QoL) subscore. Additional data were gathered regarding concomitant injury
(e.g., articular lesions or meniscal involvement) at the time of injury. One
hundred forty-seven high school and college-level football players with the
potential to continue to play in the following season were included in the
final analyses. Sixty-three percent of high school players and 69% of college
players returned to play after ACLR. Only 45% and 38% of high school and
college players respectively returned to play after surgery at their pre-injury
level. Clinically meaningful differences on several of the questionnaires were
seen between athletes (high school and college) that had not returned to play
and those that had returned to play at their pre-injury level. Of those that
had not returned to play after surgery, 50-53% of all athletes reported fear as
a contributing factor. Position played was not a predictor for the ability to
return to play after surgery. Concomitant injuries were non-significant with
respect to return to play after surgery and influence of graft type could not be
analyzed due to a wide variety of graft types among the groups.
(ACL) injuries are common among young football players. Surgical reconstruction
is currently the most common intervention to facilitate return to play, however
not all athletes are successful. Unfortunately, there is a lack of data
regarding how many football players return to play and what factors may
increase the risk of a player not being able to return to play. The purpose of
this study was to determine the percentage of high school and college-level football
players that returned to play at a minimum of 2 years after an ACL
reconstruction (ACLR) and the reasons why players did not return to play. All
patients were included in this study from the MOON
cohort if they reported football as one of the sports they participated in
since surgery or the sport they were playing at the time of their ACL injury.
These patients were interviewed regarding their return-to-play status,
advancement to the next level of competition, position played, performance
after surgery, and (if applicable) reasons for not returning to play. These
patients also completed the following validated questionnaires: International Knee Documentation
Committee (IKDC), Marx Activity Scale, Knee
injury and Osteoarthritis Outcomes Score (KOOS) sports and recreation subscore and quality of
life (QoL) subscore. Additional data were gathered regarding concomitant injury
(e.g., articular lesions or meniscal involvement) at the time of injury. One
hundred forty-seven high school and college-level football players with the
potential to continue to play in the following season were included in the
final analyses. Sixty-three percent of high school players and 69% of college
players returned to play after ACLR. Only 45% and 38% of high school and
college players respectively returned to play after surgery at their pre-injury
level. Clinically meaningful differences on several of the questionnaires were
seen between athletes (high school and college) that had not returned to play
and those that had returned to play at their pre-injury level. Of those that
had not returned to play after surgery, 50-53% of all athletes reported fear as
a contributing factor. Position played was not a predictor for the ability to
return to play after surgery. Concomitant injuries were non-significant with
respect to return to play after surgery and influence of graft type could not be
analyzed due to a wide variety of graft types among the groups.
The percentage of athletes
that returned to play after ACLR in this cohort is consistent with previous
works [ Ardern 2011, 12m follow-up, Ardern 2011,2-7 yr follow-up, Ardern 2011, systematic
review]. When further
evaluating the level of football participation, only 45% of high school
athletes and 35% of college athletes were participating in football at their
pre-injury level. These percentages are consistent with Ardern 2011
who reported that 45% of athletes were participating in sports at their
pre-injury level 2-7 years after surgery. Ardern 2012
reported that athletes that had not returned to their pre-injury level of
activity 2-7 years after surgery scored significantly lower on a custom fear
questionnaire. Consistent with this current study, fear may be a limiting
factor for all athletes that want to return to full athletic competition. This
current study confirms and continues to support the evidence that ACLR in
athletes does not guarantee full return to play. What does this mean for our
athletes? Is there a way to reduce the fear of re-injury and train athletes to
minimize their risk of re-injury? What deficits are we not addressing in our
post-operative rehabilitation in these athletes?
that returned to play after ACLR in this cohort is consistent with previous
works [ Ardern 2011, 12m follow-up, Ardern 2011,2-7 yr follow-up, Ardern 2011, systematic
review]. When further
evaluating the level of football participation, only 45% of high school
athletes and 35% of college athletes were participating in football at their
pre-injury level. These percentages are consistent with Ardern 2011
who reported that 45% of athletes were participating in sports at their
pre-injury level 2-7 years after surgery. Ardern 2012
reported that athletes that had not returned to their pre-injury level of
activity 2-7 years after surgery scored significantly lower on a custom fear
questionnaire. Consistent with this current study, fear may be a limiting
factor for all athletes that want to return to full athletic competition. This
current study confirms and continues to support the evidence that ACLR in
athletes does not guarantee full return to play. What does this mean for our
athletes? Is there a way to reduce the fear of re-injury and train athletes to
minimize their risk of re-injury? What deficits are we not addressing in our
post-operative rehabilitation in these athletes?
Written by: Kathleen
White
White
Reviewed by: Jeffrey
Driban
Driban
Related Post:
McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD, MOON Group, & Reinke EK (2012). Return to High School- and College-Level Football After Anterior Cruciate Ligament Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study. The American Journal of Sports Medicine PMID: 22922520
Great post. As rehab professionals, we all know that having a skilled surgeon is only part of the equation. Where/how the athlete rehabilitates from an ACL reconstruction is also big. I would love to know specifically where some of these study participants did their therapy….in a standard outpatient PT center, at their school with an AT, or at a sports med center. I see all too often athletes spend their first 4-6 weeks post-op doing their rehab next to TKAs and not necessarily athletes. I think this could be a big reason why they might have fear down the road…they haven't been treated like an athlete from day one. They aren't shown the sport-specific ways to properly strengthen their knee in manners that elicit responses like "Hey, I can do this on this knee…it's gonna be OK!"
BJ, I agree that we may not be treating them like athletes, but I think our issues lie in our late stage rehabilitation and not in our early rehab. Unfortunately, insurance companies tend to limit rehabilitation to a short period of time, not allowing for the appropriate monitored rehab. We also probably use up too many visits early on in the rehab process, as opposed to using more education and monitoring for the first few weeks.
Regardless – SOMETHING has to change. Kat, please figure this out quickly!
The MOON Cohort consists of patients between the ages of 12 and 36 that have undergone ACL reconstruction by one of three surgeons (Dr. Kurt Spindler, Dr. Christopher Kaeding or Dr. Rick Parker). These patients are followed up with at several clinics 2 years after ACLR; Washington University, Cleveland Clinic, The Ohio State University or Vanderbilt University. Their primary outcome measures are patient reported outcome measures and radiographs. Information regarding the study can be found here: https://clinicaltrials.gov/ct2/show/NCT00478894
From the information that I could find there was no mention of controlling for post-operative rehabilitation. Because of the large number of subjects and clinics involved in this study it is most likely that these patients are not all receiving the same standard rehabilitation. However, their results are still consistent with the findings of others regarding return to play.
In my experiece working in the rehab setting with ACL reconstructed athletes, I have found that patient compliance becomes a problem toward the end of rehab between 4-6 months. Sometimes it happens due to frustration, they become bored with rehab, or they assume that since they are able to walk and jog they do not need to work on plyometics, agility, higher level functional exercises, or sport specific exercises. They assume that since they are functional enough to do normal daily activities without pain or swelling they are able to return to sport without practicing sport specific movements under supervision. Some athletes do not allow themselves to build confidence in their abilities to perform sport specific movements in a step by step manner. Even when we as clinicians stress the importance of completing each step of the rehab process, what patients decide to do is sometimes out of our hands. It makes me wonder how many of the athletes in this study have completed a full bout of rehab from ROM to sport specific movements and how that affected their decision to return to play.
Thank you for your comment. I agree that athletes often get "restless" near the end of their rehab and this is when sports specific exercises are essential.
For this study we do not know the rehab protocol that was completed by these athletes, however the findings of this study are consistent with previous findings. A study focusing primarily on a specific post-operative rehab protocol would provide us with a better understanding of the rehab effects.