Return To Sport Criteria Research Articles

Postoperative Rehabilitation and Return-to-Sport Criteria After Distal Triceps Rupture Repair: A Scoping Review.

Distal triceps rupture is a rare injury that is commonly surgically repaired to improve elbow strength and function. Most patients are active and have goals to return to specific activities and sports. There is no gold standard rehabilitation protocol for return to sport (RTS) after distal triceps repair. To identify in the literature any criteria used for RTS after distal triceps repair. Scoping review; Level of evidence, 4. Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, level 1 to 4 studies that examined distal triceps repair and had a minimum follow-up duration of 12 months were deemed eligible for study inclusion. Exclusion criteria encompassed studies that employed nonoperative treatment, lacked specific RTS criteria, or involved revision cases. The selected studies underwent assessment regarding RTS outcomes, timelines, rates, and methodological quality. Of the initial 378 unique studies, 6 studies (including 116 patients involved in 16 different sports) met the inclusion criteria. Four of the studies reported RTS rates, with a mean of 89.3%. The duration of time for returning to sport was reported in 2 studies and varied from 4 to 6 months. The parameters most emphasized in the rehabilitation protocols were progressive range of motion exercises, followed by early immobilization and progressive strengthening exercises. Supervised therapy was reported in only 2 (33%) studies. Although all studies included a rehabilitation protocol and 5 studies included a timeline for RTS, only 1 study provided subjective criteria, and no studies utilized specific objective measurement criteria. The overall study quality was fair. This review demonstrated that the overall RTS rate after distal triceps repair was high (89.3%), with no consensus on RTS criteria. Most studies included initial immobilization followed by progressive range of motion and strengthening. Timing after surgery was used as a measure to RTS in the minority of studies and varied between 4 and 6 months. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

Return to Sport after Pediatric Osteochondral Lesions: A Systematic Review

Background: Evidence on return to sport (RTS) criteria and timelines for pediatric patients with osteochondral (OCD) lesions of the foot and ankle is limited. Methods: This systematic review evaluated RTS criteria and outcomes in this population by querying PubMed, Embase, Web of Science, CINAHL, and SPORTDiscus up to 30 May 2024. Inclusion criteria were retrospective or prospective studies that examined pediatric patients with osteochondral lesions of the foot and ankle and gave outcomes or criteria regarding RTS. Results: Five observational studies (n = 168 patients; n = 180 OCD lesions; mean age: 14.19 ± 0.47 years; mean follow-up: 42 ± 174 months) were included. Two studies (40%) used time-based criteria for RTS, two studies (40%) used mixed criteria, and the final study (20%) used milestone-based criteria. Across the mixed and milestone criteria, physical therapy (n = 3) and minimal partial weight-bearing prior to RTS (n = 4) were most frequently seen as the milestones used for assessing RTS readiness. RTS from the postoperative period ranged from 3 months to 6 months. At the final follow-up, 61.45% of patients (n = 110) were available to provide information regarding their ability to RTS. Of these patients, 80% (n = 88) achieved RTS. Conclusions: Results showed variability in RTS criteria, ranging from three to six months, with no clear patterns. Most patients returned to sport, suggesting that such individualized criteria may be effective to an extent. Future research should focus on larger, high-quality studies to develop consistent RTS protocols.

Which jump test is most sensitive for classifying ACL injury history in fatigued or non-fatigued athletes?

Introduction & Purpose In fast-paced clinical decision-making, jump-landing movement assessments are rarely used to guide return-to-sport (RTS) decisions after an anterior cruciate ligament (ACL) injury. While these tests are crucial for identifying deficits in movement execution (e.g., dynamic valgus, extended knee, knee internal rotation) that could predispose to ACL re-rupture (Kaplan & Witvrouw, 2019), identifying these deficits can be challenging. To integrate RTS movement assessments into clinical practice, the first step is to identify the most sensitive jump-landing test that can best expose remaining deficits in neuromuscular control and resulting landing kinematics associated with ACL injury. Further, RTS tests are mostly performed in a non-fatigued state although fatigued individuals often fail to reach the RTS criteria (Dingenen & Gokeler, 2017). This exploratory study aimed to rank common jump-landing tests in their ability to identify (sensitivity and classification rate) deficits in whole-body landing kinematics following ACL injury, under both fatigued and non-fatigued conditions. Methods A total of 43 volunteers were recruited into ACL group (n = 21, 11 females, 3.9 years post ACL injury) and control group (n = 22, 12 females). 3D motion data (Vicon, 250 Hz) were recorded during a single-leg forward hop (SH), single-leg countermovement jump (CMJ), single-leg triple crossover hop (COH), and single-leg 90° medial rotation hop (MRH) before and after a fatigue-inducing intervention (single-leg squats and step-ups). Thirteen joint angles (50 ms after initial contact) from the lower body, trunk, and pelvis representing the landing kinematics were calculated in OpenSim. A correlation analysis was performed to check for multicollinearity issues. Eight distinct logistic regression models (four jumps, fatigued/non-fatigued, α = .05) were computed to predict ACL injury history based on a combination of joint angles. For each model, a backward stepwise method was employed to determine which combination of joint angles resulted in the highest classification rates. Results ACL injury history was successfully predicted in seven (χ² > 4.4, p < .036) of the eight logistic regression models (Figure 1). The SH in the fatigued condition (χ² = 22.5, p = .008) demonstrated the highest sensitivity of 85.7% and a classification rate of 86%. Significant predictors for this model were knee rotation (Odds ratios [OR] = 1.537), hip abduction (OR = 1.385), hip rotation (OR = 1.525), and ankle flexion (OR = 0.771). The CMJ (non-fatigued) showed the second-highest sensitivity of 81% and a classification rate of 81.4% (p = .027). Significant predictors were knee rotation (OR = 1.440), hip abduction (OR = 1.428), hip rotation (OR = 1.297), and pelvis rotation (OR = 0.664). The MRH in the non-fatigued condition exhibited the lowest sensitivity, and no classification was possible in the non-fatigued COH model (χ² = 3.6, p = .056). Discussion & Conclusion The fatigued SH was the most sensitive jump-landing test for classifying groups and detecting kinematic differences due to previous ACL injury. Thus, we recommended the SH over other tests for RTS decision-making, as it is most likely to reveal kinematic abnormalities. Higher classification rates in the fatigued condition support RTS testing in fatigued states to better identify movement deficits. To integrate jump-landing assessments into RTS decisions in a feasible way, our future work will involve 3D motion capture using pose estimation algorithms on video data.

Are demographics, physical function and psychological response associated with return to sport at one year following ACL-reconstruction?

ObjectiveTo determine the relative contribution of each of the following aspects: demographics, physical function, and patient-reported outcome measures (PROMs), including both physical and psychological constructs, to return to sport (RTS) (any level) one-year post anterior cruciate ligament reconstruction (ACLR). DesignCross-sectional cohort study. MethodsWe included data for 143 participants (73 women, mean (SD) age 24 (5.8) years) ∼ one-year post-ACLR. Data comprised demographics, physical function (hop performance, hip and knee peak torque) and PROMs (Knee Osteoarthritis Outcome Score subscales, perceived stress, and ACL Return to Sport after Injury scale (ACL-RSI)). We then used a Z-normalized multivariable logistic regression model to establish the relative contribution of factors associated with RTS. ResultsSixty-four (45%) of the participants had returned to sport at one year post-ACLR. In the regression model, greater hip abduction peak torque (OR = 1.70, 95% CI; 1.01 to 2.84) and greater psychological readiness to RTS (OR = 2.32, 95% CI; 1.30 to 4.12) were the only variables associated with RTS (R2 = 0.352). ConclusionsThe significant contribution of hip abduction strength and psychological readiness to RTS was still relatively small, suggesting other potential factors explaining RTS which may not be captured by common RTS criteria.

Return to the Pre-Injury Level of Sport after Anterior Cruciate Ligament Reconstruction: A Practical Review with Medical Recommendations.

Returning to sport after anterior cruciate ligament reconstruction (ACLR) can be a challenging and complex process for the athlete, with the rate of return to the pre-injury level of sport observed to be less than athlete expectations. Of the athletes that do return to sport (RTS), knee re-injury rates remain high, and multiple studies have observed impaired athletic performance upon RTS after ACLR as well as reduced playing time, productivity, and career lengths. To mitigate re-injury and improve RTS outcomes, multiple RTS after ACLR consensus statements/clinical practice guidelines have recommended objective RTS testing criteria to be met prior to medical clearance for unrestricted sports participation. While the achievement of RTS testing criteria can improve RTS rates after ACLR, current criteria do not appear valid for predicting safe RTS. Therefore, there is a need to review the various factors related to the successful return to the pre-injury level of sport after ACLR, clarify the utility of objective performance testing and RTS criteria, further discuss safe RTS decision-making as well as present strategies to reduce the risk of ACL injury/re-injury upon RTS. This article provides a practical review of the current RTS after ACLR literature, as well as makes medical recommendations for rehabilitation and RTS decision-making after ACLR.

Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of the Criteria

Background: Postoperative rehabilitation is an important component of recovery after anterior cruciate ligament (ACL) reconstruction (ACLR), facilitating successful return to sport (RTS) by reducing risk factors for repeat injury. Purpose: This systematic review aimed to determine the best protocol for RTS after ACLR in children. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, Embase, PEDro, SPORTDiscus, and Web of Science databases were searched from October 3, 2014, to November 3, 2022. The inclusion criteria were the pediatric population (<18 years old) after ACLR with clear RTS criteria and/or mean/median time to RTS. Multiligament knee injuries were excluded from this study. The methodologic quality of the included articles was assessed using the methodological index for non-randomized studies (MINORS). The highest possible score was 24 points for comparative studies (ie, a study comparing 2 protocols or more). Noncomparative studies or studies with a single protocol could score a maximum of 16 points as assessed by the MINORS score. Results: The search yielded 1816 titles, and 24 were retained based on the inclusion and exclusion criteria. Every study was published between 2015 and 2022. Among the 24 studies included, 13 were retrospective and 11 were prospective. The mean MINORS score for the noncomparative studies was 13 of 16 (n = 23) and 23 of 24 for the comparative study (n = 1). The studies were categorized into unspecified clearance (n = 10), milestone based (n = 13), and combined time and milestone (n = 1). A total of 1978 patients (57% female) were included in the review. The mean age at ACLR was 14.7 years. The most common endpoint used was graft rupture (0% to 35%). In the unspecified group, the quickest RTS was 5.8 months and the longest was 9.6 months. Statistically significant risk factors for ACL reinjury included younger age and earlier RTS. The latter was a significant contributor to graft failure for combined time-based and milestone-based RTS. In the milestone-based group, the most common criteria were ≥90% limb symmetry measured using hamstring strength, quadriceps strength, and/or hop tests. The mean RTS time was 6.8 to 13.5 months. Conclusion: RTS should be delayed, when possible, especially in the younger population. A combination of quantitative tests and qualitative tests is also recommended. However, optimal RTS criteria have yet to be determined. Future prospective studies should focus on comparing the different times and milestones currently available.

Differences in Neurocognitive Functions Between Healthy Controls and Anterior Cruciate Ligament-Reconstructed Male Athletes Who Passed or Failed Return to Sport Criteria: A Preliminary Study.

Only 55% of anterior cruciate ligament-reconstructed (ACLR) athletes return to competitive sports. This brings into question the usefulness of current return to sport (RTS) criteria. High cognitive demand of sport environment clarifies the value of incorporating neurocognitive tests when making decisions regarding the time of RTS. This preliminary study aimed to compare the neurocognitive functions between healthy controls and ACLR male athletes who passed or failed RTS criteria. A total of 45 male football players, including 15 ACLR who passed RTS criteria, 15 ACLR who did not pass, and 15 healthy controls participated in this cross-sectional study. The Cambridge Neuropsychological Test Automated Battery was used to measure a battery of neurocognitive tasks, including speed of response, sustained attention, working memory, cognitive flexibility, and response inhibition. The results revealed that compared with both the ACLR-passed and healthy groups, the ACLR-failed group showed greater values of 5-choice movement time (P = .02, P = .01, respectively) but lower values of stop signal reaction time (P = .03, P = .001, respectively) and proportion of successful stops variables (P = .02). In addition, compared with the healthy group, both the ACLR-failed and ACLR-passed groups indicated greater values in between errors (P < .001, P = .008, respectively) and reaction latency variables (P = .002, P = .01, respectively) but lower values of A' (P < .001, P = .007, respectively), probability of hit (P < .001, P = .03, respectively), and percent correct trials variables (P = .006, P = .02, respectively). Our findings indicated deficits in neurocognitive functions in ACLR male athletes. In addition, poor performance in sustained attention, working memory, and cognitive flexibility measures observed in the ACLR-passed group highlighted the necessity for using a multimodal approach via implementation of neurocognitive measures in conjunction with the functional and muscular assessments when making RTS decisions.

Poster 323: Factors Impacting Return to Sport Timing Following ACL Reconstruction

Objectives: Forty-one percent of sports injuries are knee injuries. One-fifth of knee injuries involve the anterior cruciate ligament (ACL). The high incidence of ACL injuries results in approximately 129,000 ACL reconstructions in the United States each year. Timing of return to sport (RTS) after ACL reconstruction (ACLR) depends on clearance by the medical team, patients meeting objective RTS criteria, and patient selected timing. A criterion-based approach to RTS commonly includes measurements of quadriceps strength, hop performance, and subjective knee function to guide the decision-making of orthopedic surgeons and physical therapists regarding patient readiness and safety to RTS. Therefore, the purpose of this study was to assess patient-related predictors (age, sex, graft type, psychological readiness, and the duration of physical therapy) of time to pass RTS criteria. We hypothesized that patients with more positive psychological readiness, those who were still completing physical therapy, and male patients would pass RTS testing at earlier time points, while graft type and age would have no effect. Methods: Fifty-four participants between the ages of 10 and 25 years and within 5 to 15 months of ACL reconstruction who were planning to return to at least 50 hours per year of cutting and pivoting activities were included. Patients with a previous history of surgery to either knee or concomitant posterior cruciate ligament reconstruction were excluded from the study. Participants completed clinic testing when RTS was being planned. Testing included unilateral quadriceps strength in each limb (isometric at 90° knee flexion using a crane scale and 1-repetition maximum using a knee extension machine), 4 single-legged hop tests (single, crossover and triple hop for distance; 6-meter timed hop), and self-reported knee function (International Knee Documentation Committee Subjective Knee Form 2000 [IKDC], Global Rating Scale). In order to pass, participants needed scores of at least 90% symmetry for both quadriceps strength measures and all 4 single-legged hop tests as well as 90% on the IKDC and Global Rating Scale. Participants repeated clinic testing until they passed the entire testing battery in a single session. On the day of passing all RTS criteria, psychological readiness was assessed using the ACL Return to Sport after Injury (ACL-RSI) survey. The ACL-RSI is a valid and reliable outcome tool that assesses the participant’s emotional wellbeing, confidence in performance, and risk appraisal. An additional survey question was used to identify if participants were still participating in physical therapy (PT) at the time of passing RTS testing or when they had finished working with a physical therapist. PT was categorized as either a) &lt;6 months of PT, b) 6-8 months of PT, or c) &gt;8 months of PT or still currently in PT. Multivariate linear regression was used to assess the association between age, sex, graft type, ACL-RSI score, and duration of PT on the time to passing RTS testing after ACL reconstruction. An alpha level of p&lt;0.05 was set a priori. Results: The mean age of the participants in this study was 17.3±2.7 years and 50% were female. Graft type and duration of physical therapy data are presented in Table 1. The mean time for passing all components of the RTS test battery was 10.3 ±2.6 months. At the time of passing RTS testing, the mean ACL-RSI score was 86.1±14.2%. Age, sex, graft type, ACL-RSI scores and duration of PT accounted for 44.5% of the variation in the time to pass RTS testing (p&lt;0.001). Sex (β=-0.426; p&lt;0.001), graft type (β=0.340; p=0.008), and age (β=0.194; p=0.111) were the strongest predictors of time to pass RTS testing with younger age correlating with shorter RTS times. Sex (Male: 8.6±3.1 months; Female: 11.1±3.5 months) and graft type (Hamstring: 7.7± 3.9 months; Quadriceps Tendon: 10.8±2.7 months; Patellar Tendon: 11.5±2.6 months; Allografts and IT band: 7.2±1.4 months), were significant predictors of time to pass RTS criteria while PT duration and ACL-RSI were not significant predictors. Conclusions: Female patients and patients with a patellar tendon or quadriceps graft took longer to meet objective RTS criteria after ACL reconstruction. Education with female patients and those with quadriceps and patellar tendon autografts may be required to establish realistic expectations for RTS readiness. While many factors impact graft choice, time to pass RTS criteria is an additional consideration for surgeons and patients. Additionally, previous studies have shown that male patients are more likely to experience graft retear following ACLR than females. This finding could be the result of male patients returning to sport earlier than females, giving the graft less time to heal. [Table: see text]

Postoperative considerations based on graft type after anterior cruciate ligament reconstruction a narrative review.

Graft selection for anterior cruciate ligament reconstruction (ACLR) affects rehabilitation throughout the course of postoperative care. A search of PubMed and EBSCO was performed and abstracts independently reviewed by two authors. This search was also supplemented with additional evidence relevant to each phase of ACLR rehabilitation. Direct implications of graft type on clinical decisions vary throughout treatment phases, transitioning from potential differences in acute postoperative pain management immediately after surgery to facilitating sufficient and appropriate lower extremity loading in subsequent weeks. Regardless of graft type, surgical limb weakness persists throughout the course of rehabilitation; however, harvest site selection for autografts contributes to disproportionate weakness of the harvested muscle group and the potential for surgical-induced tendinopathy. In later phases of rehabilitation, as athletes are transitioning into return to sport (RTS), treatment decisions and protocols are less affected by graft type but expectations for meeting clinical milestones and the time required to do so does differ between graft types. Targeted strengthening interventions to address muscle weakness following graft harvest in autografts should be continued throughout the rehabilitation process. Lingering deficits in quadriceps strength symmetry may also influence time to meet progression and RTS criteria following graft harvest from the extensor mechanism.

Return to Sport After Primary Anterior Cruciate Ligament (ACL) Reconstruction: A Survey of The American Orthopaedic Society for Sports Medicine.

Anterior cruciate ligament (ACL) tears are a common sports injury, and typically require a prolonged post-operative rehabilitation. The purpose of this study was to survey members of the American Orthopaedic Society for Sports Medicine (AOSSM) to determine their return to sport (RTS) criteria after primary ACL reconstruction (ACLR). A 23-question, anonymous survey hosted through Google® Docs was distributed electronically to AOSSM members. This survey included questions regarding the timing, as well as any functional tests or other metrics used to determine when an athlete is ready to RTS. A total of 863 surgeons responded over four months. The most popular graft choice was bone patellar tendon bone autograft (63%). For non-pivoting sports, 43% of respondents allowed RTS at five to six months, while 31% allowed RTS at seven to eight months. For pivoting sports, 34% of respondents allowed RTS at seven to eight months, while 36% allowed RTS at nine to ten months. The most common criteria for return to non-pivoting sports include full knee motion (89%) and time after ACLR (76%). The most common criteria for return to pivoting sports include full knee motion (87%) and passing a hop test (80%). Only 21% of respondents assessed for psychological readiness to RTS. RTS occurred sooner in non-pivoting than pivoting sports, with similar RTS criteria in both groups. Most respondents did not assess for psychological readiness to RTS.

Reconsideration of Return-to-Sport Decision-Making After Pediatric ACL Injury: A Scoping Review.

Up to 90% of pediatric athletes return to sport (RTS) after anterior cruciate ligament reconstruction (ACL-R); however, <50% RTS at the same level and second ACL injury rates are up to 32%. (1) Determine which physical and patient-reported outcome measures guide clinical decision-making on RTS in pediatric athletes after ACL-R and (2) present a framework with insights from cognitive and neurophysiological domains to enhance rehabilitation outcomes. PubMed, CINAHL, Embrase, and Cochrane library databases and gray literature. Data on pediatric (<18 years) ACL-R patients, RTS, tests, and decision-making were reported in 1214 studies. Two authors independently reviewed titles and abstract, excluding 962 studies. Gray literature and cross-reference checking resulted in 7 extra studies for full-text screening of 259 studies. Final data extraction was from 63 eligible studies. Scoping review. Level 4. Details on study population, aims, methodology, intervention, outcome measures, and important results were collected in a data chart. Studies included 4456 patients (mean age, 14 years). Quadriceps and hamstring strength (n = 25), knee ligament arthrometer (n = 24), and hop tests (n = 22) were the most-reported physical outcome measures guiding RTS in <30% of studies with cutoff scores of limb symmetry index (LSI) ≥85% or arthrometer difference <3 mm. There were 19 different patient-reported outcome measures, most often reporting the International Knee Documentation Committee (IKDC) (n = 24), Lysholm (n = 23), and Tegner (n = 15) scales. Only for the IKDC was a cutoff value of 85% reported. RTS clearance in pediatric ACL-R patients is not based on clear criteria. If RTS tests were performed, outcomes did not influence time of RTS. Postoperative LSI thresholds likely overestimate knee function since biomechanics are impaired despite achieving RTS criteria. RTS should be considered a continuum, and biomechanical parameters and contextual rehab should be pursued with attention to the individual, task, and environment. There is a need for psychological monitoring of the ACL-R pediatric population.

How to Optimize Return to Sport in ACL Surgery

Anterior cruciate ligament (ACL) rupture is one of the most common sport injuries. The incidence of ACL rupture was estimated to range from 30 to 78 per 100.000 person-years. Several sport contact injuries were reported that highly associated with ACL rupture, such as football (15%) and soccer (5.2%) competition. ACL rupture was also found more common in male than female players. The anatomy of ACL originates from lateral wall of the intercondylar fossa and inserts to the tibial eminence anteriorly. It comprises of two bundles, such as anteromedial and posterolateral bundle. The femoral attachment arises from resident’s ridge to the posterior articular margin of the lateral femoral condyle. The tibial attachment is closely related to the attachment of the lateral meniscus. Return to sport (RTS) remains to be the main goal of ACL reconstruction (ACLR). However, RTS criteria remains debatable due to differences outcome measure. RTS was noted 60-80% in different sports following ACL reconstruction surgery. However, there was several factors that may affect the ACLR surgery. Concomitant ligamentous and meniscus injury may prolong the RTS. Graft choice may also contribute to the process of RTS. Bone-patellar-tendon-bone (BPTB) graft has shown to have early incorporation to the femoral and tibial tunnel due to bone-to-bone healing. Surgical technique also plays role in the early RTS. Single-bundle and double-bundle ACL reconstruction remains debatable in ACLR surgery. However, there was no differences in both surgical techniques in terms of early RTS.

High quality rehabilitation to optimize return to sport following lateral meniscus surgery in football players.

There is a paucity of studies in the literature pertaining about how to guide rehabilitation and return to sport (RTS) progression for football players that have sustained a lateral meniscus injury and subsequent surgery. These patients are clinically challenging. If they return to sport too soon, before the rehabilitation process is completed and RTS criteria have been met, functional outcomes could be non-optimal and/or associated with higher reinjury risk. The aims of this paper are (I) to provide a brief overview of the current trends in acute lateral meniscus tears surgery in football players and (II) to suggest a framework for clinicians on how to progress the player following lateral meniscus surgery. Post-operative rehabilitation approaches are different for meniscus repair and for the other surgical techniques. The main goal of all involved practitioners should be to balance the "short term success" with the "long term protection" of the athlete's health. Specific key goals and interventions in early-, mid-, and late-stage rehabilitation are provided. The most important principle is to manage the progressive increase in loading through multiple measurements including frequent medical control consultations and functional tests detailing movement quantity and quality. RTS monitoring needs to be comprehensive and interdisciplinary, incorporating state of the art tests, to achieve recovery of sport-specific fitness, optimal movement quality and on-field rehabilitation progression.

Return-to-Sport Criteria After Anterior Cruciate Ligament Reconstruction Fail to Identify the Risk of Second Anterior Cruciate Ligament Injury.

The incidence of second anterior cruciate ligament (ACL) injury after ACL reconstruction (ACLR) is high in young, active populations. Failure to successfully meet return-to-sport (RTS) criteria may identify adult athletes at risk of future injury; however, these studies have yet to assess skeletally mature adolescent athletes. To determine if failure to meet RTS criteria would identify adolescent and young adult athletes at risk for future ACL injury after ACLR and RTS. The tested hypothesis was that the risk of a second ACL injury after RTS would be lower in participants who met all RTS criteria compared with those who failed to meet all criteria before RTS. Prospective case-cohort (prognosis) study. Laboratory. A total of 159 individuals (age = 17.2 ± 2.6 years, males = 47, females = 112). Participants completed an RTS assessment (quadriceps strength, functional hop tests) and the International Knee Documentation Committee patient survey (0 to 100 scale) after ACLR and were then tracked for occurrence of a second ACL tear. Athletes were classified into groups that passed all 6 RTS tests at a criterion level of 90% (or 90 of 100) limb symmetry and were compared with those who failed to meet all criteria. Crude odds ratios and 95% CIs were calculated to determine if passing all 6 RTS measures resulted in a reduced risk of second ACL injury in the first 24 months after RTS. Thirty-five (22%) of the participants sustained a second ACL injury. At the time of RTS, 26% achieved ≥90 on all tests, and the remaining athletes scored less than 90 on at least 1 of the 6 assessments. The second ACL injury incidence did not differ between those who passed all RTS criteria (28.6%) and those who failed at least 1 criterion (19.7%, P = .23). Subgroup analysis by graft type also indicated no differences between groups (P > .05). Current RTS criteria at a 90% threshold did not identify active skeletally mature adolescent and young adult athletes at high risk for second ACL injury.

Wide Variability in Return-to-Sport Criteria used by Team Physicians After Anterior Cruciate Ligament Reconstruction in Elite Athletes—A Qualitative Study

PurposeThe purpose of this study is to explore currently used readiness to return to sport (RTS) criteria after anterior cruciate ligament reconstruction (ACLR) used in elite athletes to gain novel insights into the RTS decision-making process of professional team physicians.MethodsEighteen qualitative semistructured interviews with professional team physicians were conducted by a single trained interviewer. The interviews were used to identify team physician concepts and themes regarding the criteria used to determine RTS after ACLR. General inductive analysis and a coding process were used to identify themes and subthemes arising from the data. A hierarchical approach in coding helped to link themes.ResultsThe most important RTS criteria included muscle strength, followed by satisfactory functional testing including hop tests, a satisfactory clinical examination, joint stability, psychological readiness, time since the ACLR surgery, absence of joint effusion, subjective feeling of knee stability, pain-free return to sporting movements, completion of a sport-specific rehabilitation, and at last allied team support.ConclusionsThis study identified 4 main themes, including (1) objective findings, (2) informative feedback of the team members, (3) subjective findings, and (4) type of sport and time to surgery as having the most influence on RTS decision after ACLR. However, interviews showed that even among professional team physicians, the main criteria to RTS in these categories were inconsistent. A definitive set of conclusive guidelines could not be established and would be a fruitful and useful area for future research through further quantitative studies and international consensus meetings along the foundation of the presenting study.Level of EvidenceV, evidence-based practices, qualitative study.

Return to Sport Activities and Risk of Reinjury Following Primary Anterior Cruciate Ligament Reconstruction.

This article examines the elements that affect the return to sport (RTS) and the risk and percentages of reinjury following a prior primary anterior cruciate ligament reconstruction (ACLR). The prevalence of RTS following ACLR ranges from 71% to 83%. Concerning elements affecting RTS, a limb symmetry index score of 90 or more duplicates the likelihood of RTS and triplicates it when the International Knee Documentation Committee (IKDC) score is 95 or more, irrespective of age. Other elements recognized to be preindicative of RTS at 1 year include complete rehabilitation, age ≤25, and higher IKDC scores. The prevalence of reinjury following ACLR ranges from 1.5% to 37.5% (between 9% and 29% in the majority of reports). It has been published that 1 in 5 individuals suffers reinjury to either knee, and that male individuals are more prone to reinjure following ACLR. The highest percentage of ACLR reinjury happens in younger male (<18 years), being substantially higher than in female of the same age. Passing a combination of functional tests with predetermined cut-off points utilized as RTS criteria are related diminished ACLR reinjury percentages.

Poster 176: International Expert Consensus on Return to Sport Criteria Following Shoulder Stabilization Surgery: A Delphi Study

Objectives:A comprehensive approach to standardize the criteria of return to sport (RTS) following common shoulder procedure in athletes is required to safely return the physically active population to sport postoperatively. There is lack of studies validating the RTS criteria following arthroscopic and/or open shoulder stabilization surgery. We developed a list of widely accepted criteria of RTS following shoulder stabilization surgery using Delphi consensus methods with international experts.Methods:A working group developed a list of approximately 50 criteria. Experts included 27 world renowned shoulder surgeons from various countries who have been recognized as international experts in the field and were invited speakers to international sports medicine meetings rated their agreement to each of the listed criteria. Experts were surveyed on 3 occasions to establish consensus on the inclusion of each RTS criterion in the final list of accepted criteria of RTS after shoulder stabilization surgery. For each round, a 70% agreement was used as a cutoff for consensus. Statements without this level of agreement were excluded in subsequent rounds. Descriptive statistics were used for analysis. Predefined criteria were used to refine item lists after each survey. Final list of criteria of RTS following shoulder stabilization surgery was complied by the working group and included those that received > 75% agreement on all 3 rounds of rating by experts.Results:We initially identified 50 RTS criteria following shoulder stabilization surgery from the literature that the experts were asked to rate their agreement. Twenty-seven international experts completed the rating in all 3 rounds. The RTS criteria were divided consisted of 5 subgroups including current evidence, ideal characteristics of the RTS criteria, general considerations for RTS criteria, specific considerations for RTS criteria, and dissemination of RTS criteria following shoulder stabilization. For Round 1, the response rate was 100% and 10 (20%) of 47 criteria were eliminated leaving 37 statements for evaluation in Round 2. Round 2 had a 100% response rate, and 1 (2.5%) statement was eliminated leaving 36 criteria for the final round. Round 3 had a 96% response rate, and no statements were eliminated. Respondents agreed on a total 36 statements to define the RTS criteria following shoulder stabilization in athletes. Table 1 provides the final list of accepted criteria and the percentage of agreement for each individual criterion.Conclusions:The final list of statements agreed upon by international experts provide insight into a standardized return to sport criteria following shoulder stabilization surgery in physically active patients. This agreed upon criteria can aid those providing care to athletes in their decision making when determining optimal timing for return to sport.Table 1.Statements that reached an expert consensus above 70% in 3 rounds.

Are 6-Month Functional and Isokinetic Testing Measures Risk Factors for Second Anterior Cruciate Ligament Injuries at Long-T Follow-Up?

Second anterior cruciate ligament (SACL) injuries are a devastating complication following return to sport (RTS). Appropriate and safe RTS criteria that reduce the risk of SACL injuries are needed. The goal of this study was to investigate the relationship between functional and isokinetic testing at 6 months following primary ACL reconstruction (ACLR) as risk factors for SACL injuries. Patients with primary ACLR from 1990 to 2010 were identified. Those with 6-month postoperative functional and isokinetic testing and a minimum of 2-year follow-up were included. Functional testing included vertical jump, single-leg hop, and single-leg triple hop. Isokinetic testing included concentric quadriceps and hamstrings (HSs) strength at 60 and 180 degree/s speeds. Statistical analysis evaluated the significance of the various tests between those with and without a secondary tear. In total, 344 patients with a mean age of 26.0 ± 9.8 years at an average time of 9.1 ± 3.5 years of follow-up were analyzed. Fifty-nine patients (17%) experienced SACL injuries at an average time of 4.8 years following ACLR with 34 (58%) ipsilateral graft ruptures and 25 (43%) contralateral tears. Several isokinetic measures were significantly different between the NO SACL and the SACL groups: quadriceps 60 degree/s limb symmetry index (LSI) (75 vs. 82% p = 0.01), HS 60 degree/s LSI (92 vs. 97%, p = 0.04), quadriceps 180 degree/s involved/body weight (BW) (41 vs. 47%, p = 0.04), and HS 180 degree/s involved/BW (30 vs. 34%, p = 0.04). Patients with involved limb peak quadriceps torque value greater than 65 or 50% of BW (60 and 180 degree/s) had a 2.2 and 3.1 times higher risk of an SACL injury. Patients with certain elevated isokinetic scores in the injured limb at 6 months after ACLR experienced a higher rate of subsequent ACL injuries than those who had lower peak torque. Although a quantitative only analysis may not be sufficient to determine RTS criteria, clinicians should caution high-performing patients about the risk of subsequent ACL injury. Cohort study; 3.

An Analysis of the Increased Risk for Lower Extremity Injury Within 12 Months After Concussion and Utilization of Lower Extremity Measures for Return to Sport

Background:According to the Concussion Clinical Practice Guidelines, the typical recovery timeline post-concussion is about 7-14 days. However, recent research has shown an increased risk for lower extremity (LE) injury as early as 90 days and up to 1 year post-concussion.Purpose:The primary purpose of this study was to determine the prevalence of youth athletes who sustained a LE injury within 1 year post-concussion at Texas Children’s Hospital. The secondary purpose of this study was to describe the prevalence and utilization of LE functional testing performed by Physicians (MDs), Physical Therapists (PTs), and Athletic Trainers (ATs) as part of return to sport (RTS) clearance post-concussion.Methods:A retrospective chart review was completed consisting of patients diagnosed with a concussion by a Sports Medicine Physician from September 2018 to September 2020. The inclusion criteria were as follows: male or female, ages 8-21, and active participation in 1 or more sports. The data was collected in Microsoft Forms. Additionally, a Microsoft Forms survey was sent to Sports Medicine MDs, PTs, and ATs to assess utilization of LE functional tests. SPSS 25.0 was used for analysis with alpha level at .05. A one-sample chi-square test was utilized to compare re-injury rate to the known rate of 1%. Other proportional comparisons were run using two-sample chi-square analyses.Results:A total of 635 charts were reviewed with 527 patients participating in at least 1 sport. 12.7% (N=54) of those who sustained a concussion had either a musculoskeletal injury or another concussion within 1 year, with the highest proportion of injuries being a second concussion (33.3%) or ligament sprain (35.2%). Of the providers polled, 52.8% do not currently use a LE functional measure as part of RTS criteria. The most commonly reported reasons that providers do not use LE measures were as follows: not included in their standard of practice, lack of time, and lack of knowledge.Conclusion:The results suggest a LE test battery may be beneficial to assess LE injury risk post-concussion. Additionally, the majority of providers do not currently use LE functional measures when assessing RTS criteria. Considering the increased risk for LE injury and lack of LE functional testing completed by providers, further education about current, available LE functional testing should be provided to decrease the prevalence of LE injury after concussion. Future studies should analyze the effects of LE strengthening and functional testing on subsequent LE injury risk post-concussion.

Rehabilitation and Return to Sport Testing After Anterior Cruciate Ligament Reconstruction: Where Are We in 2022?

AbstractAthletes who sustain an anterior cruciate ligament (ACL) injury often opt for an ACL reconstruction (ACLR) with the goal and expectation to return to sports at the preinjury level. The proportion of athletes who successfully return to preinjury-level sport is low and disappointing, whereas the rate of second ACL injury in athletes under the age of 20 has been reported to be as high as 40% after return to sport (RTS). Although in recent years, new insights pertaining to RTS have been published, the lack of validity of RTS criteria after ACLR remain. The purpose of this clinical commentary is to present a critical overview of the current literature on RTS testing after ACLR.