With all the research available regarding ACL surgeries, evidence for return to sport guidelines remain undefined. Many athletes are cleared for return to sport 6-9 months post-op regardless of physical objective performance data. In fact I’ve had athletes who rehabbed elsewhere come in for a one time visit to have me evaluate them for return to sport. Upon my subjective questioning for surgical date, surgeon, graft type, rehab facility, frequency, duration etc., I find that even at 6-9 months post-op their rehab is incomplete. Either, they went to rehab for a few months and were discharged (with or without a HEP), they ran out of visits, didn’t find value in their rehab protocol or didn’t have PT covered by their insurance. During their physical performance evaluation it becomes obvious that there are some deficits that could land them back on the operating table. What’s troubling is that often these athletes have already been cleared for return to sport by their surgeon. Surgeons are very busy and often don’t have much time during follow-up visits, and they definitely don’t have a facility to watch their athletes run, jump and change directions. What they need is an accurate report of the athlete’s physical performance on a standardized test that is applicable to their desired activity level.
Returning to sport from an ACL reconstruction is a very difficult task that requires a high volume of hard work and dedication by the patient with carefully guided, structured and progressive challenges by rehab professionals. As athletes approach their 6th-7th month of rehab there are a few common physical tests that most PTs use for return to sport examination. The problem is that it can be difficult to qualify and quantify the results in a way that gives the surgeon an accurate snapshot of where the athlete is in relation to their ideal activity level and post-op stage or phase. So what does the literature say?
A recent systematic review by Harris et al, examined 49 Level 1 RCTs prior to 2012 with a minimum 2 year follow up and found that only 5 studies reported weather patients were successful in returning to sport. However, of the 49 studies, 90% did not use objective criteria and 65% did not use any criteria. In the 5 studies that did report return to sport success, 532 patients were included and 479 (90%) were returned to sport at preinjury level. The systematic review concluded that in the highest level ACL studies, most surgeons, despite the lack of objective criteria, permitted return to cutting and pivoting sports at 6 or 9 months when it was reported. There is a wealth of peer-reviewed literature dedicated to ACL reconstruction yet no conclusive guidelines exist to permit safe return to unrestricted sport. So how as clinicians are we supposed to know when our patients are ready to return to sport?
A study by Ntoulia et al, found that graft revascularization and maturity reaches satisfactory levels between 6-9 months, and 6-9 months of focused, progressive exercise should yield positive neuromuscular and strength results. So the idea that return to sport should occur at that point is not far off base, but we also know that all athletes are different and each athlete’s road to recovery sometimes takes unexpected turns. However, at some point each athlete needs to demonstrate mastery of basic body control, movement awareness and coordination tasks. Beyond that, for safe return to sport the athlete needs to be able to integrate that mastery in a reactive and progressive sequence of movements that mimic the stress, forces and fatigue involved with athletic participation. Unfortunately setting up a high quality study that can measure these variables in a large number of subjects is very difficult, which is why there are no well researched return to sport protocols that have been proven to predict preparation for high level reactive athletics. Fortunately as the field of sports medicine progresses more facilities are becoming equipped to examine athletes in three dimensional motion analysis labs with ground force plates. Which means we are getting closer to having a universally accepted standardized return to sport protocol, because we have all the movements necessary and now the equipment to record and measure the data objectively. What we are missing are the components of reactivity and fatigue in our scientific testing. Once we can measure reactivity and game like fatigue we can then begin to create a universally accepted ACL return to sport protocol that should cut down on preventable ACL re-tears or contralateral tears.