When Is It Safe to Return to Sport After ACL Reconstruction? Reviewing the Criteria

Abstract

Context: There is an ever-increasing trend toward sports, fitness, and recreation activities, so the incidence of anterior cruciate ligament sports injuries has increased. Perhaps the greatest challenge for sports clinicians is to return the injured athlete back to his/her original sport at an even greater level of functional ability than preinjury. For this, rigorous and well-researched criteria are needed. Evidence Acquisition: Using medical subject headings and free-text words, an electronic search was conducted up to October 2018. Subject-specific search was based on the terms return to play and return to sport in combination with guidelines, criteria, and anterior cruciate ligament reconstruction. Study Design: Descriptive review. Level of Evidence: Level 2. Results: Five principal criteria were found, including psychological factors, performance/functional tests, strength tests, time, and modifiable and nonmodifiable risk factors. Conclusion: The psychological readiness of the player is a major factor in successful safe return to sport (SRTS) decision making. Although strength, performance, and functional tests presently form the mainstay of SRTS criteria, there exists very little scientific evidence for their validity. More protection should be provided to athletes with known risk factors. Movement quality is important, if not more important than the quantifiable measures. As a result of the significantly high rerupture rate in young individuals, delayed SRTS should be considered preferably beyond 9 months postsurgery.

One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years

“…Since then, the issue of RTS criteria has received much attention in light of the unacceptable failure rates in young athletes cited by multiple investigations. 7,19,41,47,58,84,91,98,101 In 2016, Ardern et al 5 presented consensus statements regarding recommendations for RTS decision making from the First World Congress in Sports Physical Therapy. These authors identified the need to validate clinical tests for RTS, which include strength (rate of force development, eccentric, and endurance), neuromuscular control (dynamic functional tests and reactive agility tasks), psychological measures, and performance and skill execution.…”

Contractile rate of force development after anterior cruciate ligament reconstruction—a comprehensive review and meta‐analysis

“…125 Thus, physical/physiological performance factors, which based on the present review include RFD, may explain the better rate of return to sport of elite athletes compared to recreational athletes. While modifiable neuromuscular factors such as quadriceps strength seem to have a supporting 35 and weak association 26,126 with a successful RTS after ACLR, the present data suggest the relevance of RFD testing to identify trainable neuromuscular deficits in preparation for RTS and may be especially important for athletes who are required to perform rapid/high-force movements in training and competition.…”

Making Progress

“…In summary, I think it is clear to most clinicians in sports medicine that our progress in understanding the full implications of an ACL injury and the complexities of returning to sport has been painfully and frustratingly slow. However, as the science of the 4 publications [7][8][9]15 in this issue of Sports Health demonstrates, we are making progress. Hopefully soon, additional strong medical research will drive our treatments in the right direction; this will improve ACL injury and reinjury rates.…”

“…For those clinicians struggling with RTP issues, the review by Kaplan and Witvrouw 8 emphasizes 5 criteria to consider during the process. While strength, performance, and functional testing are used most commonly to determine safe RTP, the authors question the scientific validity of these factors, emphasizing the sobering fact that those who return to pivot and contact sports have a 4.68 times higher rate of knee reinjury than those who do not return to sporting activity.…”