Monday, May 6, 2019

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

This week, we will continue to look into considerations we should have when making return to play decisions for our ACLR athletes.  Last week, we looked at the Wren et al study, which indicated that although an athlete may have 90% LSI on this single leg hop for distance, this may not be a true representation of LSI and it does not give us an indication of what the athletes lower limb mechanics are during the performance of that test.

The Rohman et al study had suggested a series or battery of tests, not just a single test, should be considered when assessing an athlete for RTPlay following ACLR.  During our last discussion, this also raised the question that if we have a battery of tests, what is the likelihood that the athlete will pass this whole battery?

The purpose of a study by Toole et al J Orth Sport Phy Ther 2017 was to determine if athletes who met the recommended cutoffs for sports participation post op ACLR were able maintain the same level of sports participation when compared to those who did not meet the criteria.

115 young athletes (88 female, 27 male, mean age 17.2 y/o) were included in the study.  Each subject filled out an IKDC (International Knee Documentation Committee) subjective knee evaluation form and went through the following battery of tests:

  • Quadricep and hamstring testing - isokinetic test via Biodex test
  • Single leg hop for distance 
  • Triple hop for distance 
  • Cross over hop for distance  
  • 6 meter timed hop
For each of the single limb hop tests, the subject completed a practice trial and then performed 2 measured trials on each limb.  The average for the two trials was determined and LSI was calculated (univolved score/involved score X `100%).  

Of the 27 males, the average age was 18.8 y/o with the average time from surgery to return to play of 8.1 months post op.  Of the males, 51.9% were patellar tendon autografts, 40.7% hamstring tendon autograft and 7.4% were allograft.  The average score on the IKDC for men was 87.3.  Of the 88 women, the average age was 16.6 y/o with the average time from surgery to return to play of 8.2 months post op.  Of the females, 40.9 % were patellar tendon autografts, 52.3% were hamstring autografts, and 6.8% were allografts.  The average score on the IKDC for women was 87.7. The portions of athletes that met cutoffs for the individual tests ranged from 43.5% to 78.3%.  The portion of athletes that met cut offs for all hop tests was 53%, for all strength tests was 27.8% and all combined tests was 13.9%.  A higher portion of athletes who met cutoffs maintained same level of sports participation over the 1 year follow up compared to those who did not meet.

Based on these results, it makes us question if we are making the passing criteria too tough to pass.  It would be interesting to take an ACLR group and compare that to norms and see what the pass rate would be.  Although that has not been done, I would suspect we might see some interesting results and pass rates might not be what we would think they should be.  If we consider the Wren et al study we discussed last week, then even if an athlete does pass, it does not necessarily mean they had good mechanics or did not represent pathokinematics that would put them at risk for future injury. 

Are we being overly concerned about faulty biomechanics in the end stages of rehabilitation?  As rehab professionals (PTs, PTAs, ATCs, Strength Coaches) aren't we addressing this in the rehab process?  That is exactly what our next study looked at.  Next week, we will look at study by King et al Am J Sports Med 2019 where we get some insight into what athletes' biomechanics look like at the end phases or physical therapy.  If you enjoy this blog, please share with your colleague and follow us on instagrm @ bjjpt_acl_guy and twitter @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. 

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