Dr. Nessler shares his calling and passion for injury prevention and performance enhancement using the most current research and technologies available. As a passionate educator, he is driven to share with all the latest peer reviewed journals in sports medicine and orthopedics and what that means to how we train and treat our athletes.
Monday, December 2, 2013
Return to Play or Not Return to Play?
Anterior Cruciate Ligament (ACL) injuries are some of the most
common and costly injuries in sports.According to Joseph
et al in a recent study published in the Journal of Athletic Training,
knee injuries account for 60% of high school sport related surgeries and ACL
injuries account for >50% of all knee injuries suffered in high school athletics.In their study, they obtained data from over
100 high schools for a 3 year period.Based
on the number of ACL injuries reported in this data, they were able to
calculate an injury rate which came out to 6.5 ACL injuries per 100,000 AEs
(athletic exposures).If this injury
rate is applied to national high school athletic data during this same period
of time, then this equates to 215,628 ACL injuries over the 3 year period or
71, 876 ACL injuries/year.The national
average cost for ACL surgery is between $25,000 and $50,000 and according to
the above study, only 76.6% of the ACL injuries required surgery (or 55,057).That means in high school athletics, this is
an annual cost between $1.3B and $2.7B/year for ACL surgeries amongst high
school athletes.This does not include the cost of those that
are reinjured in 2 years (20% according to some studies) nor those that have
complications down the road from osteoarthritis (79% have OA in 12 years).According to this study, it also showed the
sports with the highest injury rates were women’s soccer (12.2 per 100,000
AEs), boy’s football (11.1 per 100,000 AEs) and girl’s basketball (10.3 per
With such high incidence of ACL injuries amongst high school
athletes and knowing that they are at risk for re-injury and osteoarthritis
down the line, it is important to make sure we are making the right call when
returning an athlete to sport following an ACLR (ACL reconstruction).Yet, there is not much in the literature that
quantifies when it is appropriate to return to sport and a lot of different opinions
on when it is appropriate to return to sport and what testing should be done to
make the determination.According to McCullough
et al, only 63% of HS and 69% of college football players return to sport
following ACLR.Of those only 43%
returned to the same level.So although this
is a common injury and a common procedure, there is a lot of variance in one’s
ability to return to sport.What makes
the difference between an athlete returning to sport and not?In the November issue of the American Journal of Sports Medicine, that
is exactly what the authors of the study entitled: A
Qualitative Investigation of the Decision to Return to Sport After Anterior
Cruciate Ligament Reconstruction: To Play or Not to Play, tried to
patients between the ages of 18-40 years of age (N=31) who had an ACLR with a
minimum of a 2-year follow up and preinjury participation in a sport were
included in the study.All surgeries
were performed by the same surgeon between 2002 and 2010.A 30-45 minute interview was performed by a single
examiner with each participant using a study specific question guide distilled
from the sports medicine, psychology and quantitative studies.Both a Marx activity score and perceived knee
scores were obtained as secondary outcomes.
Results:During the 3 month period, 31 patients were
interviewed (15 18-29 years old & 16 30-40 years old).64% of patients had not returned to previous
level of sport (defined as same type sport, level of play and Marx activity
score) and 36% had.Three overarching
themes emerged that determined return to play.
most frequent reason for players not returning to preinjury level and type of
sport was fear.Fear of reinjury, fear
of pain, fear of being debilitated and fear of added financial burden.
– changes in family commitments, job demands and life stages composed the
second most influential theme.
– those who did not return to their preinjury level described themselves as
being cautious, having relaxed outlook, being procrastinators and having a lack
Patients who did return to preinjury sport did have a Preinjury
and Current Marx activity score that were very close (13.0 vs. 13.0) as
compared to those who did not return to sport (12.9 vs. 5.5).So overall, those who did not return to sport
were less active overall compared to those who did.
Discussion:Several things that must be considered when
looking at this study.
·Sample size = 31.This is relatively small sample size
considering this was to include all ACLR done by one surgeon over an 8 year
·Age range – 52% of the participants in this study
were over the age of 30.69% of this group
did not return to sport.Considering
this, there are several things that may influence return to sport decision in
this group that would not be considered by the other.
oLife Stage - this age group is going to be in a
much different stage of life and very different life responsibilities (career,
family, children) than the younger age group.This may greatly influence one’s willingness to return to sport.
oFinancial impact – this age group are also
typically further along in their career and an injury greatly impacts their
ability to work and hence their financial contribution to the family unit.This may also greatly influence one’s
willingness to return to sport.
Considering the there are things we can do in the clinic to mitigate
patient’s fear with return to
this was the most frequent reason listed for not returning to sport, there are
a lot of ways to reduce fear clinically.
onset of single leg activities.Getting
a patient to do single leg activities early (within protocol) and often.Building the confidence in the limb as soon
as possible so that they can see putting weight on the leg will not result in
re-injury.Sounds basic right?Unfortunately it is not.
of training – implementing higher level of intensity earlier in the
protocol (as long as within protocol) will help in boosting confidence that
they are training for return to sport.When they feel like they are getting a workout similar to what they did
in sport, the more confident they become that they will be prepared.
specific single leg lateral and diagonal movements – again it sounds basic
but amazing how many times it is not a standard of practice.As long as within protocol, the sooner the athlete
starts lateral and diagonal single leg movements, the more confident they will
become in their stability and ability on the injured limb.
specific training – implementing sport specific drills into the rehab
process is critical to building confidence.If the first time they do this is on the field or 1-2 weeks prior to
return to sport, their confidence will not be as high as it needs to be to
return to sport safely.
coach – all too often, clinicians forget you are just as much a clinician
as you are a coach.There is a
tremendous amount of psychology that goes into coaching great players into
becoming exceptional players.If this
same psychology is applied clinically, then the athlete’s confidence is
as a clinician, you have just as much an impact on the athlete’s ability to
return to sport as the some of the psychological factors feeding into their not
returning.So, it is not just above the
shoulders of the athlete but the clinician as well!
1.Joseph A, Collins C, Henke N, Yard E, Fields S,
Comstock D.A Multisport Epidemiologic
Comparison of Anterior Cruciate Ligament Injuries in High School
Athletics.J Ath Train.2013; 48 (published online before print).
2.Tjong V, Murnaghan L, Young J, Harris D.A Qualitative Investigation of the Decision
to Return to Sport After Anterior Cruciate Ligament Reconstruction: To Play or
Not to Play.Am J Sport Med.2013 (published online before print).
3.McCullough K, Phelps K, Spindler K, Matava M,
Dunn W, Parker R, Reinke E.Return to
High School – and College-Level Football After Anterior Cruciate Ligament
Reconstruction: A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study.Am j sports med.40:2523-2529, 2012