Criteria Used to Determine Unrestricted Return to Activity After ACL Reconstruction in Pediatric and Adolescent Patients: A Systematic Review

Abstract

Background: The rates of anterior cruciate ligament (ACL) graft failure or contralateral ACL rupture range from 17% to 30% in pediatric patients after ACL reconstruction (ACLR). A contributing factor to the high reinjury rate in this population may be the limited evidence regarding appropriate criteria for allowing unrestricted return to activity (RTA) postoperatively. Purpose: To review the literature and identify the most commonly used criteria when determining unrestricted RTA after ACLR in pediatric patients. Study Design: Systematic review; Level of evidence, 4. Methods: A search was performed of the Medline/PubMed, Cochrane Central Register of Controlled Trials, Embase, CINAHL, and SPORTDiscus databases using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The authors identified studies that included pediatric patients (<19 years of age) and specified the criteria used to determine RTA after ACLR. Results: A total of 27 articles met all criteria for review, of which 13 studies only used 1 criterion when determining RTA. Objective criteria were the most common type of criteria for RTA (17 studies). Strength tests (15 studies) and hop tests (10 studies) were the most commonly used tasks when deriving RTA criteria. Only 2 studies used validated questionnaires to assess the patient’s physiological readiness for RTA, and only 2 studies used an objective assessment of movement quality before RTA. Conclusion: Only 14 of the 27 reviewed studies reported using >1 criterion when determining RTA. Furthermore, few studies used patient-reported outcome measures or lower limb kinematics as RTA criteria, indicating that more research is needed to validate these metrics in the pediatric population.

Global knee function rating more strongly influences adolescent athletes that sustain a sports‐related surgical ACL re‐injury or contralateral ACL injury

“…High athletic identity, an obsessive sport passion, and limited recent sports training experiences may combine to create inaccurate participation readiness perceptions in some adolescent athletes. Since most have not performed any rehabilitation tasks that remotely resemble the higher intensity, greater total volume sports training that they were participating in prior to their ACL injury, a single question asking them to estimate perceived knee function readiness for sports after 6–12 months of being away because of ACL reconstruction and rehabilitation might be implausible for any patient, particularly an adolescent athlete [36].…”

“…From this perspective, thinking that the ‘genie can be placed back into the bottle’ in the sense of not just normalising time zero physical and psychological functions, but also in preserving them long‐term without some form of continued maintenance requirement following index ACL injury, surgery and rehabilitation may be far‐fetched. A better objective might be to better prepare adolescent athletes to problem solve and adapt as they continue to balance task‐specific self‐efficacy with a rational level of performance anxiety or fear [9, 36, 42, 46].…”

“…Personal factors may include, but are not limited to, educational level, athletic identity, fear avoidance, self-efficacy, health locus of control, race, gender and coping styles. When the myriad of changes that an adolescent normally experiences are juxtaposed with ACL injury, surgery and rehabilitation, within their own, often unique set of environmental and personal factors, it becomes obvious that no matter how comprehensive, physical function and neuromuscular control measurements alone may lack the breadth of prognostic information needed to accurately determine return to sport participation readiness in a manner that will positively influence future health trajectories, reducing threats to good health during adulthood [9,36,42,44]. From this perspective, thinking that the 'genie can be placed back into the bottle' in the sense of not just normalising time zero physical and psychological functions, but also in preserving them long-term without some form of continued maintenance requirement following index ACL injury, surgery and rehabilitation may be farfetched.…”