Background:Reinjury rates after anterior cruciate ligament reconstruction (ACLR) are highest among young athletes, who consequently suffer from low rates of return to play. Historically, quantitative measures have been used to determine readiness to return to sport; however, they do not assess modifiable risk factors related to the quality of movement.Purpose:To determine the effectiveness of a criteria-based rehabilitation progression and return-to-sport criteria on efficient return to activity and prevention of second injury in young athletes post-ACLR.Study Design:Case series; Level of evidence, 4.Methods:Between December 2010 and 2013, 42 skeletally immature athletes (mean chronologic age, 12 years; range, 10-15 years) who underwent ACLR using ipsilateral hamstring tendon autograft were prospectively evaluated. All athletes progressed through a criteria-based rehabilitation progression; were assessed at specific time frames for strength, biomechanical, and neuromuscular risk factors predictive of injury; and were provided targeted interventions. The final return to sport phase consisted of quantitative testing as well as a quality of movement assessment of several functional movements with progressive difficulty and sports-specific loading. Clearance for unrestricted activity was determined by achieving satisfactory results on both qualitative and quantitative assessments with consideration for the demands of each sport.Results:The mean time for return to unrestricted competitive activity was 12 months. All but 3 (7%) athletes returned to their primary sport. Thirty-five athletes (83%) returned to unrestricted activity. Of the 6 (14%) who sustained a second injury, 3 (50%) were injured in sports they were not cleared for. All ACL reinjuries occurred in a cutting sport. Half of reinjuries occurred within 1 year of surgery, while the remaining occurred between 1 and 2 years. Eighty-three percent of reinjuries involved highly competitive cutting athletes.Conclusion:In our cohort, the combination of qualitative and quantitative data served as a good indicator for reducing risk and determining readiness to return to sport.

Although the incidence of anterior cruciate ligament injuries continues to rise, return to sport (RTS) rates remain low and risk of the second injury remains high. No gold-standard criteria exist for medical clearance to RTS after anterior cruciate ligament reconstruction. The lack of consensus may be driven by the multifactorial nature of the clinical decision that includes a combination of physical and psychological factors. Tools such as the Quality of Movement Assessment, which identifies physical deficits and faulty movement patterns to provide targeted recommendations for safe RTS, and the Anterior Cruciate Ligament Return to Sport after Injury Scale, which determines psychological readiness by measuring an athlete’s emotions, confidence, and risk appraisal, have been developed in recent years. This review summarizes the existing evidence regarding RTS and highlights the need for a comprehensive evaluation of an athlete’s readiness to return.

Recent research continues to demonstrate a relatively low rate of return to previous level of play among athletes following ACLR combined with a significant risk of injury to either the ipsi or the contralateral ACL. Recent research also demonstrates a growing use of a varied battery of assessments to determine readiness to return to sport as well as a lack of consensus on the ideal rehabilitation program, the criteria for clearance for return to play (both in time from surgery and functional milestones), and the nature of a conditioning program designed specifically for transitioning the cleared athlete back to competition. Due to the lack of consensus and consistency regarding rehabilitation protocols and criteria for clearance to play after ACLR, deficits in strength, neuromuscular control, and psychological readiness may exist in "cleared" athletes. These deficits may not only negatively impact sports performance but also raise the risk of re-injury. Programs designed to successfully return an athlete to previous level of play should include not only strength and conditioning aimed at restoring fitness that was compromised as a result of the injury but also include attention to psychological readiness and address deficits in neuromuscular control. Problems that exist following ACLR cannot be solved by one professional; successful rehabilitation and return to play require a coordinated effort among the surgeon, physical therapist, athletic trainer, and fitness professional. Future research is needed to determine the optimal strategy to restore the neuromuscular control, functional strength, and psychological readiness necessary for a successful return to competition following ACLR.

ObjectiveTraining patterns are commonly implicated in running injuries. The purpose of this study was to measure the incidence of injury and illness among marathon runners and the association of injuries with training patterns and workload.MethodsRunners registered for the New York City Marathon were eligible to enrol and prospectively monitored during the 16 weeks before the marathon, divided into 4-week ‘training quarters’ (TQ) numbered TQ1–TQ4. Training runs were tracked using Strava, a web and mobile platform for tracking exercise. Runners were surveyed at the end of each TQ on injury and illness, and to verify all training runs were recorded. Acute:chronic workload ratio (ACWR) was calculated by dividing the running distance in the past 7 days by the running distance in the past 28 days and analysed using ratio thresholds of 1.3 and 1.5.ResultsA total of 735 runners participated, mean age 41.0 (SD 10.7) and 46.0% female. Runners tracked 49 195 training runs. The incidence of injury during training was 40.0% (294/735), and the incidence of injury during or immediately after the marathon was 16.0% (112/699). The incidence of illness during training was 27.2% (200/735). Those reporting an initial injury during TQ3 averaged less distance/week during TQ2 compared with uninjured runners, 27.7 vs 31.9 miles/week (p=0.018). Runners reporting an initial injury during TQ1 had more days when the ACWR during TQ1 was ≥1.5 compared with uninjured runners (injured IQR (0–3) days vs uninjured (0–1) days, p=0.009). Multivariable logistic regression for training injuries found an association with the number of days when the ACWR was ≥1.5 (OR 1.06, 95% CI (1.02 to 1.10), p=0.002).ConclusionIncreases in training volume ≥1.5 ACWR were associated with more injuries among runners training for a marathon. These findings can inform training recommendations and injury prevention programmes for distance runners.

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