Summary

We aim to build consensus in order to standardize and optimize the initiation of return to play functional testing protocols following anterior cruciate ligament reconstruction.

Abstract

Purpose

Despite advances in surgical technique and rehabilitation following anterior cruciate ligament (ACL) reconstruction, re-injury rates after return to play (RTP) are high and return to pre-injury level of sport within the first 12 months remains low. Currently, there is controversy and no consensus on the optimal battery of tests or clear thresholds that predict athletic readiness for RTP. Our study purpose is to investigate factors that influence provider decisions to initiate RTP functional testing following ACL reconstruction. Our goal is to build consensus in order to standardize and optimize the initiation of RTP functional testing protocols following ACL reconstruction.

Methods

A 38-point questionnaire was created to obtain information on factors influencing initiation of RTP testing and specific functional testing protocols used following ACL reconstruction. The questionnaire was vetted by a small panel of expert allied health professionals (Orthopedic Surgery, PhD, Physical Therapy, ATC) and distributed to a select group of high volume academically affiliated orthopedic surgeons and allied health providers. Survey results were analyzed statistically.

Results

A total of 48 survey responses were recorded: 35 orthopaedic surgeons (73%) 13 athletic trainers, and physical therapists (27%). The most important factors (1-5) that influenced initiation of RTP testing were (chi-squared, p=0.0013):
1) Presence of pain - 96% of respondents indicated an acceptable VAS = 2 2) Time since surgery - Significant variability existed amongst surgeons (p<0.01); 47% respondents suggested 6-8 months as optimal, with 38% confirming 4-6 months, and 16% confirming 8-12 months
3) Thigh girth/Quad strength - Significant variability existed amongst providers; 31% responded greater than 80% of uninvolved limb, 31% responded greater than 85%, while 22% responded greater than 90% of uninvolved limb
4) Presence of effusion - Majority of respondents would only initiate testing with trace/no effusion, and
5) Pivot shift - 75% responded that a pivot glide was the highest acceptable grade to initiate RTP while 22% report Grade of No Pivot was necessary. KT-100 and Lachman were “not important” factors in the decision to initiate RTP testing (chi squared, p=0.0066). Regarding range of motion (ROM), no respondent would initiate functional testing with a ROM deficit >5°. 84% would initiate testing with ROM within 3-5°, while 16% responded that full ROM is necessary. 90% of respondents would not initiate RTP testing with gait asymmetry while 83% would not initiate testing with asymmetry or pain on single leg squat. Regarding the use of subjective scores to initiate RTP testing, psychiatric readiness/confidence outcome survey was “most important”, followed by IKDC, SANE, and VAS. Tegner, KOOS, and Lysholm were considered “not important” by the majority of surgeons as a factor to decide initiation of RTP testing. 72% of respondents indicated imaging studies did not influence RTP decision making.

Conclusion

While there remains a general lack of consensus regarding the initiation of RTP testing following ACL reconstruction, this survey has identified several areas of relative concordance. The majority of respondents determined that initiation of RTP testing should be only considered when: VAS= 2, trace or no effusion, ROM within 3-5 degrees of the opposite limb, examination demonstrated pivot glide or no pivot shift, no gait asymmetry, or pain on single limb squat. Timing of RTP testing and thigh girth/quad strength thresholds for initiating RTP remain controversial. Future work is required to prospectively validate these threshold criteria to determine their correlation with athlete performance on RTP functional testing protocols and during RTP.