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Return to play following ACL reconstruction; do we need more time? Part 1

“When will I be able to compete again?”. The question I seem to be asked multiple times a day as an MSK physiotherapist, especially in relation to Anterior Cruciate ligament (ACL) reconstructions. Patients who have undergone this surgery seem to be bombarded with a wide variance of answers, creating fear and avoidance which potentially leads to poorer outcomes. This potential for underperforming worries me because this injury accounts for 40% of sporting knee injuries (NHS.uk, 2018) and the significant proportion of these patients in my clinical caseload.

ACL rehabilitation remains slightly more personal to me, following a skiing accident in my youth I was unfortunate enough to suffer a rupture, however the proceeding treatment was ultimately my inspiration to become a Physiotherapist. This topic therefore holds a special place in my heart, driving my ambition for excellence in management. Through this series of posts, I aim to explore the literature and challenges of return to play guidelines following ACL reconstruction.

My current clinical environment is within the NHS, a community outpatient department that covers three large hospitals, all of which offer ACL reconstruction surgery from around 5 surgeons. Whilst employed within the NHS I have been fortunate enough to work closely with the consultants performing this surgery, allowing me to develop the service in line with the evidence base and the surgeons in the future. The high level of input and long recovery time of this surgery highlight the importance of strong outcomes, to facilitate a robust and timely return to activity.

 

Return to Play

Return to play itself poses an issue though, it is contextual and multifactorial, therefore we must first understand the concept of RTP and how to define it. Gray (2009) defined RTP as “the process of deciding when an injured or ill athlete may safely return to practice or competition”. This definition itself leaves me with more questions than answers; how do we define safe? How can we make our decision? Making sense of the literature is therefore quite challenging. With there being no single, widely accepted criteria or even test for RTP, it makes things even more challenging.

When we look at the basics of return to play percentages, the disparity is quite vast, particularly when reviewing differing patient cohorts, but even within cohort the variation is marked. Return to play percentages in elite athletes range between 76% and 95% within 1 year of surgery (Walden 2011, Brophy 2012, Zaffignini 2014). A near 20% variance within the same age group, sport type and level of activity highlights this issue clearly. When we dig deeper into this literature though, we get mixed messages regarding the success of RTP – Brophy et al (2012) indicating athletes play fewer games and shorter periods post injury, however, a more recent study by Lai et al (2017) reported no performance difference pre to post injury, once a full RTP protocol had been completed. This could be due to the patient group receiving a very high level of input, averaging between 5 and 9 rehabilitation sessions per week, a time commitment that for NHS patients would be extremely difficult to achieve, but could influence outcomes all the same.  Evidence in elite sport does tend to feed into non-elite rehabilitation however, providing strong aspirations for our care. Whether this is attainable in practice remains to be seen, but hints at the reasoning for differences between groups.

Sadly, amateur athletes have a much lower RTP percentage; 80% returning to ‘some form of sport’ and only 55% returning to their previous level of sport (Kvist et al, 2005). This trend continues to long term outcomes, with incidence of maintaining sporting activity reducing as time increases, and residual functional deficiencies still being present up to 5 years post-surgery (Frobell et al, 2013) Furthermore, Notarnicola et al’s (2016) retrospective study of 80 amateur athletes presented that of the 47.5% returning to their pre-injury sport, more than half were forced to reduce the intensity, level or time that they played for. Level of rehabilitation, number of sessions, pre-injury fitness level and decision-making framework for RTP could all influence this relatively low success rate. These studies sadly omitted these facts, limiting what information we can utilize, however Frobell et al (2013) has similar outcomes in a large cohort study in which the rehabilitation protocol, and patient demographics are relatable to my NHS caseload. These papers do not appear to be outliers in this area though, with plenty of supporting studies existing and very little to the contrary (Cheecharern 2018, Lee et al 2008, Langford et al 2009). Does this then show the need for development, or are we expecting too much? I certainly hope it is the former.

When assessing RTP a commonly used indicator for positive or negative outcome is re-injury rate, this seems to be an almost over-simplified outcome when reviewing such a complex subject. Of those who return to sport there is a comparatively high level of re-injury; 9-30% (Wasserstein et al 2015) and up to 62% stated by Shelbourne et al (2009), both of which were completed using amateur athlete participants. Elite level players are considered to be at much lower risk (Lai et al, 2017), this could simply be due to the increased input they receive, or the residual effects of the higher-level pre-injury fitness. Within practice then, a simple lack of poor outcome is not accurate or detailed enough to use as an outcome measure, certainly when a negative outcome is quite so catastrophic. It seems that we require something more specific to help guide our decision making.

 

Factors Affecting Return To Play

Historically a large quantity of the research has been focused on graft choice when trying to account for discrepancies in return to play rates, however more recent literature appears to disagree with this early belief (Culvenor et al, 2019). The two most popular graft choices currently being hamstrings and bone-patella-bone (B-P-B), whilst in more elite sport; synthetic grafts are being explored to facilitate faster returns to competition. Within these umbrella graft types even more variance exists; single bundle, double bundle and alterations in drilling technique. There stands a plethora of systematic reviews disputing any difference in relation to RTP times and functional ability level between techniques. This appears to remain true even up to 2 years post operatively, although passive laxity tested in isolation may be superior with a double bundle technique (Li et al 2011, 2012 and 2014, Riboh et al 2013, Jansen et al 2017). The KANON trial; a high quality, large randomized control study with a 2 and 5 year follow up, compared early surgical management with delayed surgery across both hamstring and B-P-B grafts. This showed delayed surgical input improved outcomes, with no clinical difference between graft choice in non-elite athletes (Frobell et al 2013). Further to this a recent BMJ case study highlighted an elite footballer returning to premiership level football within 8 weeks of rupture, having had no surgical intervention, the player also passed an 18 month follow up with no detrimental effects (Weiler et al 2015).  Whilst single case studies are not the gold standard for rigor in research, and this is an elite athlete without the lifestyle factors of our ‘normal’ patient cohort, it does pose some interesting points that may dispute the influence of graft choice further.

Consideration must be given to donor site when beginning rehabilitation post reconstruction, the consensus being to treat the graft site as an acute soft tissue tear, aiming to negate any chance of rupture (Kartus et al, 1997). No published research uses donor site injury/rupture as an outcome measure, or comments on its prevalence, however attention is vital when the possible outcomes could limit RTP so heavily. Donor site healing is said to be complete in 70% of patients 6 months post operatively, with the remaining 30% completed by 12 month follow up (Yazdanshenas et al, 2015), however studies looking into this subject fail to assess the rehabilitation process to achieve the results. I feel this should be a considered factor for RTP, especially as the donor site soft tissues maintain their strength deficits longer than any other muscle group (Frobell et al 2013), could this be a missing element to our decision-making process?

Age plays a considerable role in return to play timings and effects the overall success rate. This is particularly pertinent for the younger (18-25 age group) who statistically have a better RTP percentage (57%) and improved likelihood of returning to previous level, however are at greater risk of re-injury when they do compete again (Ardern et al 2012). This could be due to the type and level of sport that the younger age group expect to return to, when considering re-injury rates. The same study reports under 18s’ have a lower RTP rate, indicating that the improvement of 18-25 age group could be due to developmental differences in muscular strength and control. I feel this should push us as Physiotherapists to over emphasize rehabilition for these patients, because their previous control and fitness levels may not have been sufficient in the first place. Conversely Dahm et al (2008) found a much higher percentage of RTP in over 50’s (86%), however this is compared to pre-injury sport level, which was markedly lower than the younger age group and not supported by other literature.

The type of sport that athletes wish to return to appears to be one of the largest factors for whether a person returns to play successfully or not. Patients wishing to return high level competitive sports, or level 1 and 2 sports which involve cutting, jumping and pivoting having a measurably lower return rate than those returning to less dynamic sports (Feller et al, 2012). These types of sport impose much higher stresses on the knee joint, include proprioceptive challenges and require greater motor control. It would be sensible to think then, that this area should be a large part of these patients rehabilitation, however this dynamic control appears to be a smaller area of focus for rehabilitation within both practice and the literature (Frobell et al, 2013. Grindem et al, 2016. Culvenor et al, 2019). Whilst no literature directly compares increased training in this manner against outcomes, our treatment of all musculoskeletal conditions focuses on the patient’s functional needs, so should we be further emphasising this in our ACL reconstruction management?

 

This post has reviewed the subject of, and factors influencing return to play. The emerging consensus being our rehabilitation and evaluation of readiness being crucial to success. The second part on this subject will explore the utilization of differing assessments of readiness, range of protocols and how these can improve our outcomes.

 

Reference List:

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Brophy, R. Schmitz, L. Wright, R. et al. (2012). Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med; 40:2517–2522.

Cheecharern, S. (2018). Return to sport and knee functional scores after anterior cruciate ligament reconstruction: 2 to 10 years’ follow-up. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation and Technology, Volume 12, Pages 22-29, ISSN 2214-6873

Culvenor, A. Barton, C. (2019). It is time to stop wasting time and money debating graft types and surgical approaches for ACL injuries: The secret probably lies in optimising rehabilitation. [Blog] British Journal of Sports Medicine Blog. Available at: https://blogs.bmj.com/bjsm/2017/09/20/time-stop-wasting-time-money-debating-graft-types-surgical-approaches-acl-injuries-secret-probably-lies-optimising-rehabilitation/ [Accessed 19 Jan. 2019].

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Feller, J. & Webster, K. (2012). Return to sport following anterior cruciate ligament reconstruction. International orthopaedics, 37(2), 285-90.

Frobell, R. Roos, H. Roos, E. Roemer, F. Ranstam, J. Lohmander, L. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ (Clinical research ed.), 346, f232. doi:10.1136/bmj.f232

Gray, J. (2009). Phases of Rehabilitation after Injury: An Evidence-Based Literature Review. Bok Smart.

Grindem, H. Snyder-Mackler, L. Moksnes, H. Engebretsen, L. Risberg, M. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine, 50(13), 804-8.

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Kartus, J. Stener, S. Lindahl, S. Engstrom, B. Eriksson, B. Karlson, J. (1997) Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts. Knee Surgery  5: 222.

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Shelbourne, KD. Gray, T. Haro, M. (2009). Incidence of subsequent injury to either knee within 5 years after anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2009;37(2):246-251.

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Yazdanshenas, H. Madadi, F. Madadi, F. Washington, ER. Jones, K. Shamie, AN. (2015). Patellar tendon donor-site healing during six and twelve months after Anterior Cruciate Ligament Reconstruction. Journal of orthopaedics, 12(4), 179-83. doi:10.1016/j.jor.2015.05.018.

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