Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play

Ardern CL, Webster KE, Taylor NF, & Felller JA. British Journal of Sports Medicine. 2011;45: 596-606. 

Anterior cruciate ligament (ACL) reconstruction is often performed in an effort for an athlete to return to sporting activity.  General outcomes are successful, but it remains unclear how many people return to play and participate at their preinjury levels.  This study was a systematic review with the purpose to determine return-to-sport outcomes (e.g., return to participation at preinjury levels) after ACL surgery.  Forty-eight studies that evaluated return to sport in 5770 participants were included in the review.  Average follow-up time was 41.5 (range 12 to 85) months and the mean age at follow up was 25.1 (range 13 to 60) years of age.  Patellar tendon autograft was used 69% of the time and 20% had hamstring tendon autografts.  Eighty two percent of the participants had returned to sport at follow-up, and only 63% reported to be at preinjury level of participation in sport.   A quality assessment revealed that 19 studies inadequately described the participant population, 18 inadequately reported preinjury participation level, and 18 failed to report number of participants returning to preinjury level of participation.

As clinicians, we are aware that outcomes following ACL reconstruction are favorable for return to normal function.  However, outcomes for returning to a preinjury level of participation do not seem as favorable.   What is interesting is that in this review, only 44% of the participants returned to competitive sports, while 82% returned to some sporting activity.  The remaining 18% never return to a sporting activity.  Biomechanics have been demonstrated to be returned to almost normal; however this may not be the only factor.  Approximately 90% of the participants reported normal knee function outcomes, yet identified other non-biomechanical factors (e.g., fear of reinjury, lifestyle changes, fear of job loss) as to why participants did not return to play. These non-biomechanical factors may be a result of psychosocial factors or neuromuscular deficits.  Our clinical evaluation tools for return to play criteria are limited in ability to determine preparation in either of these areas.  Strength and function may appear normal, but rehabilitation needs to be all encompassing to appropriately prepare an athlete for return to play at preinjury levels.  Has anyone had any success stories of how they appropriately addressed all areas for an athlete to be adequately prepared for return to play?  Also, in a seemingly abundant area of research, few studies met appropriate quality assessment criteria for generalizations to be made.  We still need to improve the ACL research that is being conducted by gathering and reporting the appropriate information.  Furthermore, the average follow up time was less than 4 years.  For successful outcomes to be deemed, ACL reconstruction outcomes need to be investigated longer term as well.  Do you think that we should continue to focus on restoration of biomechanics, or are there other areas that you think need to be addressed in ACL reconstruction rehabilitation programs?    

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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Ardern CL, Webster KE, Taylor NF, & Feller JA (2011). Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. British Journal of Sports Medicine, 45 (7), 596-606 PMID: 21398310