This real issue has been shown previously in research by Toole et al (2017) and Welling et al (2018) who showed that only 11-14% of non-elite athletes respectively passed all discharge criteria by at least 8-9 months post-op ACLR. To strengthen this body of research, a similar trend was seen in a group of ACLR patients here in Perth, Western Australia (Edwards et al., 2018).
The authors recently followed-up with 113 non-elite ACLR patients (75 males, 38 Females) at an average of 12 months post-op and found some very concerning things.
Here are some of their key findings:
- 63% of the 113 returned back to pre-injury level of sport; which is consistent with previous research by Ardern et al (2011).
- 50% of those who returned to sport were considered to have conducted "incomplete rehab". Note: "Complete" rehab was defined as meeting current best practice guidelines of supervised rehab for at least 6 months that included hopping, agility and landing exercises; followed by either independent or supervised return to sport.
- Those that conducted "Complete" rehab were 10x more likely to pass discharge criteria, and were 8x more likely to RTS
- Those that returned to sport, only 23% passed all discharge criteria.
Note: "Passing" discharge criteria was considered when ALL of the following was met:
- >90% LSI on peak quads strength
- >90% LSI on peak hamstrings strength
- >90% LSI on single leg hop test
- >90% LSI on triple leg hop test
- >90% LSI on triple crossover hop test
- >90% LSI on 6m timed hop test
(NB: FAIL was considered if just one of these tests was not met)
So as you can see, pretty alarming statistics from a typical group of ACLR patients that we all might come across in our daily practice.
The biggest concern however is that with over 75% of ACLR patients returning back to high risk cutting/pivoting sports WITHOUT passing discharge criteria, it significantly increases their risk of graft re-injury or an ACL injury to their other limb.
This was shown in a recent paper on professional male soccer players who were shown to have a 4x greater risk of ACL re-injury when they returned to sport without passing all discharge criteria (Kyritsis et al, 2016).
Take home messages:
To lower the risk of ACLR injury and increase the likelihood of returning back to pre-injury sport, ACLR patients need to:
1) Conduct a period of supervised rehab for at least 6 months, that includes hopping, jumping and landings and a structured return to sport plan
2) Pass a series of strength and function tests before being allowed to return to unrestricted training and sport
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- Toole, A.R., et al., Young Athletes Cleared for Sports Participation After Anterior Cruciate Ligament Reconstruction: How Many Actually Meet Recommended Return-to-Sport Criterion Cutoffs? J Orthop Sports Phys Ther, 2017. 47(11): p. 825-833.
- Welling, W., et al., Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatol Arthrosc, 2018.
- Edwards, P.K., et al., Patient Characteristics and Predictors of Return to Sport at 12 Months After Anterior Cruciate Ligament Reconstruction: The Importance of Patient Age and Postoperative Rehabilitation. Orthop J Sports Med, 2018. 6(9): p. 2325967118797575.
- Ardern, C.L., et al., Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med, 2011. 45(7): p. 596-606.
- Kyritsis, P., et al., Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br J Sports Med, 2016. 50(15): p. 946-51.