Just 44% of athletes returned to competitive sport after ACL reconstruction, according to a systematic review and meta-analysis published in the British Journal of Sports Medicine (1). Forty-eight studies that evaluated 5,770 patients were included in the systematic review and meta-analysis.
Study of 120 Level 9 School-Age Athletes
Physical therapists Scot Bauman, PT, DPT, and Bill Claussen, PT, wanted to see how patients at Shelbourne Knee Center compared to this national average. They studied 120 school-age competitive athletes who underwent an ACL reconstruction using a contralateral patellar tendon graft at Shelbourne Knee Center between 2009 and 2013. Participants were Level 9 athletes, primarily high-school soccer, basketball and football players (76 female and 44 male).
Prior to surgery, patients completed pre-op rehab focused on achieving symmetric range of motion (ROM), minimal swelling, normal gait mechanics and adequate strength/leg control. Once this was achieved, surgery was performed. Use of a patellar tendon graft (PTG) from the contralateral knee allowed for unrestricted rehabilitation and an earlier return to sports.
Rehab goals after surgery were divided between the ACL knee and the graft donor knee:
- ACL knee: Attain full ROM and swelling reduction
- Donor knee: Low-intensity, high-repetition strengthening exercises for tendon regeneration
Patients continued rehabilitation until they attained symmetry between the knees, as measured by:
- Goniometric measurement for ROM
- Quadriceps muscle strength on the Cybex isokinetic test measured at 180 and 60 degrees per second
- Isometric single leg press
- Single leg hop for distance
After achieving symmetry, each patient was allowed to begin a gradual progression back to his/her sport.
Nearly Double the Return to Sport Rate
Eighty percent (96) of the 120 Level 9 athletes—nearly double the percentage in the systematic review and meta-analysis—were able to get back to the same level of sport or higher, as measured by the activity rating scale (2).
Female athletes had a higher rate of return to sport than male athletes (2):
- Females: 83% (63 out of 76)
- Males: 75% (33 out of 44).
This contradicts conventional thinking that females are less likely to return to sport than males. The reason for the higher return to sport rate among females is unknown. “It may have to do with increasing the size of the ACL in females during the reconstruction,” says Bauman. Physical therapists at Shelbourne Knee Center plan to study this in the future.
All of the athletes were able to return to the same sport at a recreational level.
Symmetry Drives Return to Sport
“All athletes want to feel normal and function normally. If you don’t have symmetry between the knees, it will be impossible for them to succeed in progressing their activities and returning to sport,” says Bauman.
Pre-op rehab and use of a contralateral PTG in ACL reconstruction both facilitate symmetry. Many orthopedic surgeons don’t realize the importance of attaining symmetry between the knees before surgery.
Bauman and Claussen reported their findings in the poster session at the 2018 Indiana American Physical Therapy Association and Kentucky American Physical Therapy Association Joint Conference, held in September 2018 in Louisville, Ky. They also will be giving a presentation on the study at the Combined Sections National Meeting of the American Physical Therapy Association in January 2019 in Washington, DC.
The two physical therapists also presented results of their study about strengthening the quadriceps after ACL reconstruction at the regional meeting.
For more information about ACL rehabilitation, call 888-FIX-KNEE.
References
- Arden CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011;45(7):596-606.)
- Bauman S, Claussen W. Return to competitive sports after ACL reconstruction. Poster session, 2018 Indiana American Physical Therapy Association and Kentucky American Physical Therapy Association Joint Conference, September 2018, Louisville, Ky.