Research Review: Simple Rules For ACL Return To Sport. Plus ONE BIG problem exposed!
Long arguments can be made over ACL Return to play criteria.
Most stem from a time based criteria (typically surgeons) as well as objective testing criteria (typically rehab coaches).
I think most of us could agree that it's best to consider both!
However, within each category there should be a minimal viable standard which is achieved. I'm not sure we know exactly what that is just yet, or if we will ever know definitively what that exactly would look like.
Here is an interesting article that talks strictly about a time based approach. Which is important to understand. The findings in the study were very telling, and it provides a very simple answer to a lot of questions clinicians will be asked early on by both athletes and parents. Which is: "When will I be playing again?"
I like this study because it looks at just athletes returning to "Level 1" sports - which is your more demanding sports including jumping, running, cutting, etc.
- 106 subjects were included
- This was a 2 year follow up study
- Typical RTS criteria was measured (hamstring/quad strength, limb symmetry, hop testing, etc.)
- Subjects returned to level 1 sport between 5-23 months after surgery. Not all subjects passed the RTS criteria prior to participating in Level 1 sports
- Just 14% of subjects who returned to level 1 sport between 5-11 months had actually passed the RTS criteria
- Just 55% of subjects who returned to level 1 sport between 12-23 months had actually passed the RTS criteria
- During the first nine months after surgery, a later return to sport was significantly associated with a lower reinjury rate. For every one month delay in return to sport, the reinjury rate was reduced by 51 %.
- Patients who participated in level I sports earlier than nine months after surgery sustained 39.5 % reinjuries (15 of 38), compared to 19.4 % knee reinjuries (7 of 36) in those who returned to level I sports later than nine months after surgery.
- Of the 55 patients who failed RTS criteria, 21 (38.2 %) suffered knee reinjuries. Only one of the 18 patients (5.6 %) who passed RTS criteria suffered a knee reinjury.
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My 2 Cents
The study is nice because it give a pretty cut and dry number associated with the time based approach to Return to Sport. 9 months is clearly a minimum standard that should be abided by in most circumstances. As reinjury rates were significantly higher when RTS happened prior to 9 months. After 9 months the reinjury rate was much less despite (in my opinion) a VERY poor success rate of subjects actually passing the return to sport criteria.
HERE is the problem!
In my opinion, too many people are still focused on what exact tests are necessary to be included in the "functional" portion of the return to sport testing. I think with this study there is pretty solid evidence about 9 months being a fairly well accepted time based approach. However, many people are still arguing over what is the optimal objective testing that functionally tells if the subject is ready.
We are looking at the wrong problem. Look at the last bullet point, only 18 patients passed the RTS criteria out of the 106....
Of the 18 who passed, only 1 of the 18 (5.6%) suffered a knee reinjury.
Now I realize that is a very small sample size. But in my opinion, it is not the RTS testing that is failing us as clinicians....
It is our ability to actually get these athletes to ACTUALLY PASS the return to sport criteria in a respectable time. These subjects were given 2 years, and yet only 18 subjects passed out of the 106.
THAT IS EXTREMELY SAD!
Maybe we should stop focusing so much on what tests are best and actually take a hard look in the mirror at ourselves and take an initiative to actually learn how to properly progress clients in the clinic in a manor that would allow for them to actually PASS the return to sport criteria within a 9-12 month timeline (and for Pete's sake! Hopefully at least by 24 months).