Athletes After Anterior Cruciate Ligament Reconstruction Cleared for Sports
Participation: How Many Actually Meet Recommended Return-to-Sport Criteria
AR, Ithurburn MP, Rauh MJ, Hewett TE, Paterno MV, & Schmitt LC. J Orthop Sports Phys Ther. 2017; Online
Ahead of Print October 26, 2017.  
Take Home Message: Most athletes are NOT meeting accepted
clinical cutoffs for strength and functional testing prior to returning to
sport after an ACL reconstruction.
It is recommended that clinicians
use objective criteria to make return-to-play decisions for patients after an
anterior cruciate ligament (ACL) reconstruction. It remains unclear how many
athletes who are cleared to play meet suggested criteria and if those who meet
the criteria are more successful in returning to pre-injury levels of activity.  Therefore, the authors investigated the
proportion of athletes who met predefined criteria for strength, hop testing,
and patient-reported outcomes and whether meeting the criteria made an athlete
more likely to maintain their pre-injury level of physical activity/sport
participation.  The criteria were an International Knee Documentation Committee subjective form (IKDC) score > 90, quadriceps
and hamstring strength limb-symmetry indices > 90%, or single-leg hop
test symmetry > 90%, or a combination of these criteria. The
researchers assessed the above criteria in 115 young athletes within 4 weeks of
return-to-sport clearance, and then reassessed their activity levels one year
later.  Just over half of the athletes
met all hop testing criteria, and less than half met the criteria for the
patient-reported outcome.  Furthermore,
just under 30% met the criteria for their quadriceps and hamstrings strength,
and only 14% met all criteria.  About 66%
of athletes maintained their physical activity one year later, and this was more
common among those that met both strength criteria (81%) compared with those
who did not meet both (60%). 
Interestingly, no differences were found for physical activity level for
those who met all criteria, hop tests, or individual criterion.
The authors demonstrate that an
athlete is more likely to maintain physical activity levels one year after returning
to play when they meet return-to-sport criteria based on strength, and that an
alarming number of athletes are not achieving this criteria prior to returning
to play. This finding shows that we should emphasize strength indices.  The other symmetry measures and
patient-reported outcome criteria were less effective at differentiating which
athletes would continue at the same activity level at one year after returning
to play. This may be because 1) other factors can influence a person’s physical
activity (e.g., graduating from school, other life commitments), 2) these
measures at the time of return to play are not as informative as changes in them
over the next year, or 3) these measurements fail to accurately reflect the state of a patient. It would have been
informative to see how these measures changed over time and if they predicted
who would experience increases in joint symptoms or new injuries.  Patient-reported outcomes have been reported
in previous posts to be good at differentiating readiness for functional
testing. Clinicians need to do a better job using standardized strength cut-offs
because they seem to be linked with a higher likelihood of success in physical
activity levels, in addition to assessing their psychological readiness. The
fact that less than 1 in 3 athletes met the strength criteria is alarming and
shows a need for us to slow down and think about what is beneficial to the
athlete in the relative short term (return to sport) as well as even longer
term (20 years later).      
for Discussion:  What criteria are you
utilizing for return to sport after an ACL reconstruction? 
by: Nicole Cattano
by: Jeffrey Driban