This study details development of an evidence-based return to sport assessment protocol for patients after ACL reconstruction, and analysis of 263 patients, highlighting inadequacy of routine clinical assessment and importance of detailed objective assessment prior to returning to competitive sport.
Objectives: After Anterior Cruciate Ligament Reconstruction (ACLr), patients expect to Return To Sport (RTS) at their pre-injury level. However, this often does not happen, and re-injury after ACLr is also not uncommon. Determination of a practical combination of valid tests is necessary to aid in the decision-making process regarding timing of a performance-based RTS with a reduced risk of re-injury. This study details the development and preliminary results of a simple, efficient, and evidence-based RTS assessment implemented in a clinical setting.
A systematic review of the literature was conducted, using publications addressing factors influencing RTS or re-injury risk after ACLr. The most frequent factors associated with return to sport and risk of re-injury were extracted and used to develop our assessment protocol; specifically, the type of tests and the pass or fail criteria. This included: Psychological questionnaires (ACL-RSI and IKDC), anthropometric measurements (height, weight, KT-1000 knee laxity, leg length) and functional tests (peak isometric knee extension and flexion strength, single leg Y-Balance test, and single leg hop for distance, hop for height, and side hop endurance). After confirmation of the protocol, all ACLr patients were routinely assessed at approximately 9 months postoperatively.
Development of an evidence-based time-efficient protocol based around limb symmetry assessment proved successful, with the typical duration of the assessment 45 min, when performed in a standard consulting room. We have currently assessed 263 ACLr patients (152 males, 111 females; 28.9 ± 11.3 y; 75.7±14.4 kg, 1.73 ± 0.14 m; 10 ± 2 months from surgery). Preliminary analysis indicates that 81% of patients failed at least one component; whilst 57% failed more than one component. The most commonly failed components were in quadriceps and hamstring strength, and vertical hop tests, for which nearly 50% of patients failed. Moderate correlations were found between each of the hop tests, and also between each hop test and quadriceps strength. Differences in results were found for different surgeons, and motion capture analysis of the kinematics revealed that many patients exhibited a large limb asymmetry for joint range of motion and movement variability, particularly in the valgus/varus plane.
Application of an evidence-based, simple, RTS protocol within a private practice is feasible, and allows surgeons to make more informed objective decisions about timing of an athlete’s RTS. The importance of this testing is highlighted by the finding that despite traditional clinical determinants suggesting patients are ready to return to sport, preliminary results from our assessments indicate otherwise, suggesting that traditional clinical criteria would return players to sport when re-injury risk is relatively high. Longer follow-up of this cohort will allow a better understanding of the capacity of this assessment to predict re-injury and hopefully reduce the prevalence of re-injury. Furthermore, normative data may provide an even more robust decision regarding a patient’s capabilities in their expected sport or activity.