Clare L Ardern

Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play

Background An athletes intention to return to sport following anterior cruciate ligament (ACL) injury is a major indication for surgical intervention. Purpose The purpose of this review was to determine postoperative return-to-sport outcomes after ACL reconstruction surgery. Study design Meta-analysis and systematic review Methods Electronic databases including Medline, Embase, SPORTDiscus and CINAHL were searched from the earliest possible entry to April 2010. Studies were included that reported the number of patients returning to sports participation following ACL reconstruction surgery. The results were presented using the World Health Organizations International Classification of Functioning, Disability and Health as a framework and combined using proportion meta-analyses. Results Forty-eight studies evaluating 5770 participants at a mean follow-up of 41.5 months were included for review. Overall, 82% of participants had returned to some kind of sports participation, 63% had returned to their preinjury level of participation, and 44% had returned to competitive sport at final follow-up. Approximately 90% of participants achieved normal or nearly normal knee function when assessed postoperatively using impairment-based outcomes such as laxity and strength, and 85% when using activity-based outcomes such as the International Knee Documentation Committee knee evaluation form. Fear of reinjury was the most common reason cited for a postoperative reduction in or cessation of sports participation. Conclusion The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes.

Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction Surgery Two-thirds of Patients Have Not Returned by 12 Months After Surgery

Background: An athlete’s desire to return to sport after anterior cruciate ligament (ACL) injury is a major indication for ACL reconstruction surgery. Typical clearance to return is 6 to 12 months postoperatively. Purpose: To investigate the return-to-sport rate and participation level of a large cohort at 12 months after ACL reconstruction surgery. Study Design: Case series; Level of evidence, 4. Methods: Data were analyzed for 503 patients who participated in competitive-level Australian football, basketball, netball, or soccer after ACL reconstruction surgery using a quadruple-strand hamstring autograft. Inclusion criteria included participation in competitive sport before the ACL injury and clearance from the orthopaedic surgeon to return to sport postoperatively. Patients completed a self-report questionnaire regarding preoperative and postoperative sports participation and the Cincinnati Sports Activity Scale. The International Knee Documentation Committee (IKDC) knee evaluation form and hop tests were used to evaluate knee function. Results: Sixty-seven percent of patients attempted some form of sports activity by 12 months postoperatively; 33% attempted competitive sport. Of those who did not attempt any sports activity by 12 months, 47% indicated that they were planning to return. Men were significantly more likely than women to return. Patients who played sports with a seasonal competition, versus a year-round competition, were significantly more likely to return by 12 months. Patients with normal postoperative knee function (IKDC category A), versus those with nearly normal function (IKDC category B), were no more likely to return, but patients with good hop test results (≥85% limb symmetry index) were more likely to return than patients with poor results (<85%). Conclusion: People may require a longer postoperative rehabilitation period than that typically advocated to facilitate a successful return to competitive sport after ACL reconstruction surgery. The relationship between postoperative knee function and return-to-sport outcomes at 12 months after surgery was inconclusive.

Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors

Background The aim of this study was to update our original systematic review of return to sport rates following anterior cruciate ligament (ACL) reconstruction surgery. Method Electronic databases were searched from April 2010 to November 2013 for articles reporting the number of patients returning to sport following ACL reconstruction surgery. Return to sport rates, physical functioning and contextual data were extracted and combined using random-effects meta-analyses. Data from the original review (articles published up to April 2010) were combined with data from the updated search. Results Sixty-nine articles, reporting on 7556 participants, were reviewed. On average, 81% of people returned to any sport, 65% returned to their preinjury level of sport and 55% returned to competitive level sport after surgery. Symmetrical hopping performance (d=0.3) and the contextual factors of younger age (d=−0.3), male gender (OR=1.4), playing elite sport (OR=2.5) and having a positive psychological response (d=0.3) favoured returning to the preinjury level sport. Receiving a hamstring tendon autograft favoured returning to competitive level sport (OR=2.4), whereas receiving a patellar tendon autograft favoured returning to the preinjury level sport (OR=1.2). Conclusions Returning to sport varied according to different physical functioning and contextual factors, which could warrant additional emphasis in postoperative rehabilitation programmes to maximise participation.

Return-to-Sport Outcomes at 2 to 7 Years After Anterior Cruciate Ligament Reconstruction Surgery

Background: Most people have not returned to their preinjury level of sports participation at 12 months after anterior cruciate ligament (ACL) reconstruction surgery. Twelve months’ follow-up may be too early to assess return-to-sport outcomes accurately. Purpose: This study was undertaken to evaluate the medium-term return-to-sport outcomes after ACL reconstruction surgery. Study Design: Case series; Level of evidence, 3. Methods: A self-report questionnaire was used to collect data at 2 to 7 years after ACL reconstruction surgery regarding preinjury sports participation, postoperative sports participation, and subjective knee function. The main inclusion criteria were participation in regular sports activity before injury and the attendance at routine surgical follow-up appointments. Results: A total of 314 participants (mean age, 32.5 ± 10.2 years) were included at a mean 39.6 ± 13.8 months after ACL reconstruction surgery. At follow-up, 45% were playing sport at their preinjury level and 29% were playing competitive sport. Ninety-three percent of the study sample had attempted sport at some time after their ACL reconstruction surgery. Those who had not attempted their preinjury level of sport by 12 months after surgery were just as likely to have returned to preinjury level by 39 months after surgery as those who had played sport by 12 months (risk ratio, 1.1; 95% confidence interval, 0.76-1.6). Conclusion: Less than 50% of the study sample had returned to playing sport at their preinjury level or returned to participating in competitive sport when surveyed at 2 to 7 years after ACL reconstruction surgery. Return to the preinjury level of sport at 12 months after surgery was not predictive of participation at the preinjury level in the medium term, which suggests that people who return to sport within 12 months may not maintain their sports participation.

Psychological Responses Matter in Returning to Preinjury Level of Sport After Anterior Cruciate Ligament Reconstruction Surgery

Background: Up to two-thirds of athletes may not return to their preinjury level of sport by 12 months after anterior cruciate ligament (ACL) reconstruction surgery, despite being physically recovered. This has led to questions about what other factors may influence return to sport. Purpose: To determine whether psychological factors predicted return to preinjury level of sport by 12 months after ACL reconstruction surgery. Study Design: Case control study; Level of evidence, 3. Methods: Recreational and competitive-level athletes seen at a private orthopaedic clinic with an ACL injury were consecutively recruited. The primary outcome was return to the preinjury level of sports participation. The psychological factors evaluated were psychological readiness to return to sport, fear of reinjury, mood, emotions, sport locus of control, and recovery expectations. Participants were followed up preoperatively and at 4 and 12 months postoperatively. Results: In total, 187 athletes participated. At 12 months, 56 athletes (31%) had returned to their preinjury level of sports participation. Significant independent contributions to returning to the preinjury level by 12 months after surgery were made by psychological readiness to return to sport, fear of reinjury, sport locus of control, and the athlete’s estimate of the number of months it would take to return to sport, as measured preoperatively (χ22 = 18.3, P < .001, classification accuracy = 70%) and at 4 months postoperatively (χ24 = 38.7, P < .001, classification accuracy = 86%). Conclusion: Psychological responses before surgery and in early recovery were associated with returning to preinjury level of sport at 12 months, suggesting that attention to psychological recovery in addition to physical recovery after ACL injury and reconstruction surgery may be warranted. Clinical screening for maladaptive psychological responses in athletes before and soon after surgery may help clinicians identify athletes at risk of not returning to their preinjury level of sport by 12 months.

A systematic review of the psychological factors associated with returning to sport following injury

Background Psychological factors have been shown to be associated with the recovery and rehabilitation period following sports injury, but less is known about the psychological response associated with returning to sport after injury. The aim of this review was to identify psychological factors associated with returning to sport following sports injury evaluated with the self-determination theory framework. Study design Systematic review. Method Electronic databases were searched from the earliest possible entry to March 2012. Quantitative studies were reviewed that included athletes who had sustained an athletic injury, reported the return to sport rate and measured at least one psychological variable. The risk of bias in each study was appraised with a quality checklist. Results Eleven studies that evaluated 983 athletes and 15 psychological factors were included for review. The three central elements of self-determination theory—autonomy, competence and relatedness were found to be related to returning to sport following injury. Positive psychological responses including motivation, confidence and low fear were associated with a greater likelihood of returning to the preinjury level of participation and returning to sport more quickly. Fear was a prominent emotional response at the time of returning to sport despite the fact that overall emotions became more positive as recovery and rehabilitation progressed. Conclusions There is preliminary evidence that positive psychological responses are associated with a higher rate of returning to sport following athletic injury, and should be taken into account by clinicians during rehabilitation.

2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern

Deciding when to return to sport after injury is complex and multifactorial—an exercise in risk management. Return to sport decisions are made every day by clinicians, athletes and coaches, ideally in a collaborative way. The purpose of this consensus statement was to present and synthesise current evidence to make recommendations for return to sport decision-making, clinical practice and future research directions related to returning athletes to sport. A half day meeting was held in Bern, Switzerland, after the First World Congress in Sports Physical Therapy. 17 expert clinicians participated. 4 main sections were initially agreed upon, then participants elected to join 1 of the 4 groups—each group focused on 1 section of the consensus statement. Participants in each group discussed and summarised the key issues for their section before the 17-member group met again for discussion to reach consensus on the content of the 4 sections. Return to sport is not a decision taken in isolation at the end of the recovery and rehabilitation process. Instead, return to sport should be viewed as a continuum, paralleled with recovery and rehabilitation. Biopsychosocial models may help the clinician make sense of individual factors that may influence the athletes return to sport, and the Strategic Assessment of Risk and Risk Tolerance framework may help decision-makers synthesise information to make an optimal return to sport decision. Research evidence to support return to sport decisions in clinical practice is scarce. Future research should focus on a standardised approach to defining, measuring and reporting return to sport outcomes, and identifying valuable prognostic factors for returning to sport.

The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction

Background This cross-sectional study aimed to examine whether appraisal of knee function, psychological and demographic factors were related to returning to the preinjury sport and recreational activity following anterior cruciate ligament (ACL) reconstruction. Method 164 participants completed a questionnaire battery at 1–7 years after primary ACL reconstruction. The battery included questionnaires evaluating knee self-efficacy, health locus of control, psychological readiness to return to sport and recreational activity, and fear of reinjury; and self-reported knee function in sport-specific tasks, knee-related quality of life and satisfaction with knee function. The primary outcome was returning to the preinjury sport or recreational activity. Results At follow-up, 40% (66/164) had returned to their preinjury activity. Those who returned had more positive psychological responses, reported better knee function in sport and recreational activities, perceived a higher knee-related quality of life and were more satisfied with their current knee function. The main reasons for not returning were not trusting the knee (28%), fear of a new injury (24%) and poor knee function (22%). Psychological readiness to return to sport and recreational activity, measured with the ACL-Return to Sport after Injury scale (was most strongly associated with returning to the preinjury activity). Age, sex and preinjury activity level were not related. Conclusions Less than 50% returned to their preinjury sport or recreational activity after ACL reconstruction. Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity. Including interventions aimed at improving this in postoperative rehabilitation programmes could be warranted to improve the rate of return to sport and recreational activities.

Hamstring strength recovery after hamstring tendon harvest for anterior cruciate ligament reconstruction: a comparison between graft types.

PURPOSE The purpose of this study was to investigate hamstring strength after harvest of 1 or 2 hamstring tendons for anterior cruciate ligament reconstruction. METHODS We recruited 50 individuals who had returned to regular sporting activity to participate in a comparative study at a mean of 32.5 months after anterior cruciate ligament reconstructive surgery (30 in semitendinosus-gracilis group and 20 in semitendinosus group). Isokinetic hamstring strength (at 60 degrees/s and 180 degrees/s with the peak torque and torque produced at 60 degrees, 90 degrees, and 105 degrees of knee flexion recorded) and isometric hamstring strength (at 30 degrees, 90 degrees, and 105 degrees of knee flexion) were measured, and the standing knee flexion angle was used to evaluate functional hamstring strength recovery. RESULTS No significant differences between the groups were found in any of the isometric or isokinetic strength measures or in the standing knee flexion angle. No relation was found between the standing knee flexion angle and the isometric hamstring strength results obtained at 105 degrees of knee flexion (r(2) = 0.034). CONCLUSIONS These findings show that the choice of hamstring tendon graft-that is, semitendinosus alone or semitendinosus and gracilis-is unlikely to significantly influence postoperative hamstring strength outcomes in athletes returning to sports postoperatively. Both graft choices showed strength deficits of between 3% and 27% compared with the nonoperated limb, indicating that hamstring strength deficits persist despite successful completion of rehabilitation. The results also show that the standing knee flexion angle should not be used as a surrogate clinical measure of hamstring strength. LEVEL OF EVIDENCE Level III, retrospective comparative study.

Fear of re-injury in people who have returned to sport following anterior cruciate ligament reconstruction surgery

OBJECTIVES To examine fear of re-injury in athletes who had returned to regular sports participation following anterior cruciate ligament reconstruction surgery. DESIGN Cross-sectional case series. METHODS A self-report questionnaire was used to collect data 2-7 years following surgery. Key inclusion criteria were regular participation in sport prior to injury and participation in sport at the time of the study. RESULTS A sample of 209 (88 females, 121 males) at a mean of 39.6 ± 13.8 months post surgery participated. Overall, participants did not express fear of re-injury, scoring >6/10 (where 10 was the most positive response) on all questions. In terms of the total score and for six out of eight questions, participants who returned to their pre-injury sports level had significantly less fear of re-injury than those who had not returned to their pre-injury level. Females had significantly more concern than males about the environmental conditions experienced while playing (mean 6.1 compared to 7.5). On three out of eight questions, individuals who had surgery more than 3 months after injury had a greater fear of re-injury than those who had their surgery closer to the time of injury. CONCLUSIONS Athletes participating in sport 2-7 years following their anterior cruciate ligament reconstruction generally appear to do so without fear of re-injury. However, gender, the timing of surgery following injury and the level of sport the athletes returned to may be associated with fear of re-injury following surgery.