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Return to Sport After ACL in the Young Athlete

Stephanie Gould Pht, Naudira Stewart P.R.T

• In youth aged 6-18 y.o., ACL injuries occur at a rate of 130/100,000 people per year

• Rate of ACL tears rising 2.5% yearly in teen girls, 2.2% annually in teenboys

• Incidence of injuries in young athletes :– Year-round competition– Early specialization– Intensive training

The ACL epidemic

• Rates of re-injury:– In young athletes (<20-25y.o) =

approx 23%– Studies report rate of re-injury of the

same knee as high as 29%– Studies report rate of ACL tear in the

contralateral knee is as high as 19%• Rates of return to sport:

– Only 40-65% return to previous levelof sport activity

– Despite 90% presenting with normal knee function (Stability, ROM and strength)at 6-9mos post

Reconstruction Surgery, Not a Magic Pill

• How to know if/when a young athleteis ready to return to sport?? – No consensus in RTS Criteria– And very few protocol use functional

criteria to assess readiness for RTS• Best way to get them there??

– No consensus in rehab protocols

WHY CAN’T WE ALL JUST AGREE?

• Time after surgery continues to be the dominant criteriafor RTS

• Recommended time before RTS varies in the literatureanywhere from 3 to 12 months! (Kvist, 2004)

• BUT:– Neuromuscular deficits can persist > 11 mos– 9/10 fail quad power @ 6 mos (Neeter, 2006)– Complete ligamentization takes 10-12mos in humans

(Li, 1993)• Also, if magical projected return time passes, frustration

mounts and this becomes mentally challenging.

Timing isn’t everything

Factors Affecting Athletes Return to Sport

• Pre-injury status• Associated knee injuries• Time to treatment / time to

surgery• Surgical technique• Knee kinematics• Rehab protocol• Compliance• Achieved level of muscle

function

• Patients activity level

• Social factors (family, work, etc)

• Functional knee stability

• Knee symptomatology

• Motivation

• Level/intensity of sport

• Psychological factors

Challenges with Teenage Athletes

• Risk-taking behaviours• Socialization/peer-pressure• Attention span• Motivation levels• Physiological and mental immaturity

IMPORTANT TO WORK WITH A THERAPIST WHO HAS EXPERIENCE WITH YOUNG PATIENTS AND WHO CAN MAKE THERAPY SESSIONS ENGAGING AND

BENEFICIAL!

During Rehab Process

PHYSIO

Rehab: Pre-operative Phase

• 1 (or more) appointment to teach home program– Ensure full ROM, strength pre-operatively– Wean from knee immobilizer ASAP– Bike ++, ROM, stretch, strengthen (incl hips,

core), proprioception

• Eliminate pain/swelling• Restore full knee extension

ROM• Gradually progress knee flexion

ROM• Maintain patellar mobility• Restore volitional quads control• Restore independent

ambulation

Rehab: Weeks 1-4

• Closed kinetic chain exercises• Progressive hamstring strengthening• Quadricep strengtheing with emphasis on

Eccentric control• Proprioception• Core and glute strengthening

Rehab : Weeks 4-12

• 12 weeks: start training in a gym (including leg press, legcurls)

• 20 weeks: start jogging at PT discretion• 24 weeks: first isokinetic testing to determine readiness

for plyometrics and sports-specific training in the therapeutic setting

Rehab: Weeks 12-24

1. Running/ sprinting 2. Straight line stops/starts3. Bilateral Plyometrics4. Lateral shuffles5. Running figure-8s6. Backwards running7. Cutting/pivoting8. Closed space agility drills9. Cariocas10. Single leg hops (progressing

difficulty)

Progressive Sports Training (starting at Month 6 )

Once the athlete has passed the Isokinetic testing with favorable results RTS training begins

• Time since surgery• Knee ROM/absence of joint effusion• Knee joint stability• Strength• Proprioception• Dynamic knee function• Neuromuscular function• Aerobic capacity• Sports-specific testing• Psychological readiness

Crucial Factors in RTS (Barber-Westin & Noyes, 2011)

A battery of tests is best to assess readiness for return to sport – Noyes et al

1. Isokinetic testing2. Knee ROM, effusion, stability tests3. Single-leg hop tests

Triple hop for distance, Cross-over hop for distance, Fatigue side hop test

4. Star Excursion Balance Test 5. Drop jump testing (with video review)6. Lower Extremity Function Test for agility7. Validated patient-reported outcome measures

A. IKDC B. ACL-RSI

RETURN TO SPORTBattery of tests

1. Isokinetic testing

2. ROM, Stability Tests

3.Single-leg hop Tests

4.Star Excursion Balance Test

5. Drop jump Testing

6. Lower Extremity Function TestL.E.F.T

• IKDC (International Knee Documentation Committee Questionnaire)

• Proven validity, reliability and re-test reliability (Irrgong, 2001)

• ACL-RSI (ACL – Return to Sport Index)• 12 item questionnaire• High sensitivity (0.97), moderate specificity

(0.63) (Muller, 2014)• High reliability, validity and test/re-test

reliability (Kvist, 2004)

7. Validated Questionnaires

• Return to sport is a PROCESS• Games + team practice brings chaos and high

speed, require quick reactions and confidence• Start with individual skills, then partner drills,

group drills, game simulation drills, practice games, partial games, then finally completegames

But wait …

Maintenance after Discharge • Don’t neglect a program of PREVENTATIVE exercises

– PEP program, FIFA-11 program• Neuromuscular training decreases an adolescent female

athlete’s risk of ACL injury by 72%• Program should include plyometric training, technique

training, ++ feedback about proper form, and continuedstrength training

Conclusion

“ When you candemonstrate that you

are ready! ”

“ When can I go back to my sport? ”

REFERENCES• Ardern, C., Webster, K., Taylor, N. and Feller, J. (2011). Return to sport

following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. The British Journal of Sports Medicine. Vol 45, Issue 3: pp 596-606.

• Barber-Westin, S. and Noyes, F. (2011). Objective Criteria for Return to Athletics After Anterior Cruciate Ligament Reconstruction and Subsequent Reinjury Rates: A Systematic Review. The Physician and Sports Medicine. Vol 39, Issue 3: pp 100-110.

• Kvist, J. (2004). Rehabilitation Following Anterior Cruciate Ligament Injury. Sports Medicine; 34(4):pp269-280.

• Labella, C., Hennrikus, W., Hewett, T. (2014). Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention. Pediatrics. Vol 133, e1437

• .A Multicenter Orthopedic Outcomes Network (MOON) Cohort Study. (2012). Return to High School and College-Level Football After Anterior Cruciate Ligament Reconstruction. American Journal of Sports Medicine.

• Muller, U. (2014). Predictive Parameters for Return to Pre-Injury Level of Sport 6 Months Following ACLR Surgery. KSSTA.

• Munro, A. & Herrington, L. (2011). Between Session Reliability of Four Hop Tests and the Agility T-Test. Journal of Strength and Conditioning Research. 25(5):pp 1470-1477

• Noyes, F., Barber, S., & Mangine, R. (2004). Abnormal Lower Limb Symmetry Determined by Function Hop Tests after Anterior Cruciate Ligament Rupture. The American Journal of Sports Medicine, 19(5), 513-518

• Nussbaum, E. Return to Play: Evidence-based Criteria. www.UOANJ.com

• Plisky, P., Rauth, M., Kaminski, T., & Underwood, F. (2006). Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopedic Sports Physical Therapy. Vol 36(12): pp 911-919.

REFERENCES

• Wacek, A. (2011). Functional Testing for Return to Sport after Anterior Cruciate Ligament Repair. CyberPT.

• Zaffagnini, S., Grassi, A., Serra, M., & Marcacci, M. (2015). Return to Sport after ACL Reconstruction: How, When, and Why? A Narrative Review of Current Evidence. Joints. Jan-Mar; 3(1): pp 25-30.

REFERENCES

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