RTPlay Following ACLR - How Do We Know When Is The Right Time?

One of the biggest questions in sports medicine right now is how do we know when an athlete is ready to return to play (RTPlay) following an anterior cruciate ligament reconstruction (ACLR)?  It is one of the biggest questions we get from coaches, from parents and from the athlete.  It is also one of the questions that we don't really know how to answer.  Is it a time based decision?  6 months, 9 months, 1 year or more?  Or is a criteria based decision?  If it is criteria based, what are the criteria?  Or is it a combination of time based and criteria based?

Before we look to answer these questions, we must first ask, why does it matter?  We know there are ~250,000 to 300,000 ACL injuries every year in the US.  We also know that ~20% reinjure in 2 years (Holm et al Am J Sport Med 2012) and that number goes up to 30% at 5 years (McCullough et al Am J Sport Med 2012).  According to a systematic review and meta analysis by Wiggins et al Am J Sport Med 2016, one in four youths who tear their ACL will suffer another ACL injury at some point in their athletic career.  Further, Rugg et al Am J Sport Med 2014 showed that an athlete who tears their ACL prior to a DI career are 8xs more likely to reinjure their knee at some point during their athletic career.   Now these statistics are staggering, but unfortunately, a reality of where we currently are.  This highlights the importance of preventing the primary injury in the first place, but once that has happened, how do we safely return an athlete to sport?

A recent study by Faltstrom et al Am J Sport Med 2019, highlighted this fact.  The purpose of this study was to follow female soccer players who had an ACLR and compare them to matched healthy norms to see if there is a variance in 1) rate of new traumatic and non-traumatic knee injuries, 2) proportion of players that quite soccer, and 3) player reported activity level and satisfaction level changed.

Methods: A total of 117 active female soccer players (age 19.9 +/-2.5 years) 18.9 months (+/- 8.7 months) after ACLR and 119 knee healthy female soccer players (age 19.5 +/- 2.5 years) matched from the same teams were prospectively followed for 2 years for new knee injuries, other injuries, soccer playing level, activity level and satisfaction with activity level and knee function.

Results:  Players with ACLR had a higher rate of new ACL injuries (19 vs. 4 per 100 player years), other traumatic knee injuries (29 vs. 16 per 100 player years) and non-traumatic knee injuries (33 vs. 9 per 100 player years) as compared to controls.  During the 2 year follow up, 62% of players with ACLR quit soccer as opposed to 36% of controls.

The conclusion of this study was that female soccer players with ACLR had nearly 5 fold higher rate of new ACL injuries, a 2 to 4 fold higher rate of other new knee injuries, and quit soccer at a much higher degree.  So the obvious point here is that we need to prevent the primary injury.  But despite that, why is it that reinjury rates are so high.  Is it that the rehabilitation is inadequate and not properly preparing the athlete for return to sport?  Is it that we are returning the athlete too quickly?  Or is that we simply don't know how or what we should be testing to ensure they are ready to return to play?

We simply do not have the answer to these questions but we can start digging into this a little more.  Obviously, there are areas where we can improve on the rehabilitation, however that is beyond the scope of this series.  But we do need to figure out how can we return athletes to sport in a safer way that is based on the literature and in a way that can be more reproducible, reliable and efficient.  Because we know, based on the above study as well as previous studies, there is an impact on future joint health as well as overall physical health.  When athletes who have been participating in sports their entire life suddenly stop doing sports, there is an impact on their overall physical fitness. 

For the professional athlete, we also know there is an impact on the longevity of their athletic career.  In a study by Mai et al Am J Sports Med 2017, the authors showed that NFL players who had an ACLR had a significant decrease in athletic performance for 2 years after return to play and they shortened their athletic career by 2 years.  So, if we are having these kinds of results at the pro level, then there has to be a way to improve upon what we are currently doing. 

Next week, we will start to dig into just that.  WE will dig in to see what the research tells us we should look at and some ways we can objectively do that.  If you enjoy this blog, please share with your colleagues and follow us on instagram @ bjjpt_acl_guy and twitter at @acl_prevention.  #ViPerformAMI #ACLPlayItSafe

Dr. Nessler is a practicing physical therapist with over 20 years sports medicine clinical experience and a nationally recognized expert in the area of athletic movement assessment and ACL injury prevention.  He is the founder | developer of the ViPerform AMI, the ACL Play It Safe Program, Run Safe Program and author of a college textbook on this subject.  Trent has performed >5000 athletic movement assessments in the US and abroad.  He serves as the National Director of Sports Medicine Innovation for Select Medical, is Vice Chairman of Medical Services for USA Obstacle Racing and movement consultant for numerous colleges and professional teams.  Trent has also been training and a competitive athlete in Brazilian Jiu Jitsu for 5 years.