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

Last week we started our discussion regarding returning an athlete to play following an anterior cruciate ligament reconstruction (ACLR).  This is a hot topic in sports medicine and one without a really clear answer.  To start our discussion we looked at several studies which indicate athletes are at greater risk for reinjury following a primary ACL injury and ACLR.  For those that do return to play following the primary ACLR, the Faltstrom et al Am J Sport Med 2019, study showed that athletes who suffered a second ACL injury were not only at greater risk for another knee or ACL injury but were also more likely to discontinue their sport all together.   We concluded our discussion talking about the impact that a primary ACLR has on athletic performance.  Specifically the Mai et al Am J Sports Med 2017, which showed that NFL players not only reduced their performance up to 2 years following a primary ACLR but also reduced their professional career by 2 years. 

So, obviously we need to prevent the primary ACL injury.  However, what we also need to do is get better at determining when the athlete is ready for return to play.  Unfortunately there is not a concesus in the literature or in the standard of practice on what should be assessed.  Melick et al Br J Sports Med 2016 performed a systematic review of the literature from 1990 to 2015.  The aim of this study was to develop an evidence based statement for rehabilitation after ACLR.  This literature review included studies that addressed the following clinical topics:

1.     Pre-operative predictors of post-operative outcomes

2.     Effectiveness of physical therapy

3.     Open and closed chain quadriceps exercises

4.     Strength and neuromuscular training

5.     Electrostimulation and electromyographic feedback

6.     Cryotherapy

7.     Measurements of functional performance

8.     Return to play

9.     Risk for reinjury

Overall, 90 studies were included in the systematic review for the basis of the authors evidence statement.  For the purposes of our discussion, we are going to look at the recommendations for RTPlay.

Based on the systematic review, the studies suggest that the following criteria should be included as a part of the RTPlay decision making process.

1.     Psychological measures – the two most commonly referenced are the TSK-11 (Paterno et al Sport Health 2018) and the ACL-RSI (Webster et al Am J Sport Med 2018, Webster et al Am J Sport Med 2019).

2.     Battery of tests for determining the quantity and quality of movement

3.     Tests which measure single limb performance

4.     A measurement of limb symmetry index

5.     A measurement of and obtaining a minimum of 90% limb symmetry index

This comprehensive approach, based on the literature, should provide us data to make a much more informed decision.  End of the day, it should allow us to make sure we are providing our athlete with the most informed decision to make a safe return to play.

Based on this systematic review, this seems pretty clear.  We add this to our return to play assessments and we should be good.  Sadly, it is not that clear cut.  For example, let’s just take a look at LSI (limb symmetry index).  This is simply a measure of the variance between the right leg and the left leg.  Seems very clear that setting the standard at 90% of the non-involved limb would be reasonable. 

However, a review of the literature shows us this is not so clear.  Rohman et al Am J Sports Med 2015 looked at this issue and looked at LSI in the ACLR athlete and compared that to healthy norms.  Couple of key findings from this study was that 93% of non-injured healthy norms had an LSI of 85% or >.  They also found that athletes that underwent an ACLR had some degradation of the non-involved leg.  This makes sense to those of us that have been involved in the rehab of these athletes since we know these athletes are not near as physically active during rehab as they are during sport.  As such, it makes sense there is some muscle atrophy, associated weakness and degradation of proprioceptive awareness that occurs in the non-involved leg during rehab. 

This led the authors to look at this further in which Rohman et alAm J Sports Med 2015 performed a retrospective case series of 122 athletes who had an ACLR to see what the impact is on the non-involved extremity.  Next week, we will dive into this study and continue our discussion on the results of the Melick et al study.

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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.