Anterior Cruciate Ligament Reconstruction Return-to-Sport Decision-Making: A Scoping Review

Abstract

Context: Clinical guidelines support the use of testing batteries to assess athlete readiness for return to sport (RTS) and risk of reinjury after anterior cruciate ligament (ACL) reconstruction (ACL-R). There is no consensus on the composition of the testing batteries. Test selection is based mainly on commonality in research, personal preference, and equipment availability. Including athletic performance assessments (APA) used in the athlete’s sport may assist RTS decision-making for stakeholders. Objective: To determine whether APA for speed, agility, strength, or cardiovascular endurance are (1) used in ACL-R RTS literature and (2) indicative of RTS or reinjury rates. Data Sources: A systematic search was performed in MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, Web of Science, and ProQuest Dissertations and Theses Global. Study Selection: Eligibility criteria were as follows: (1) athletes between 6 months and 2 years post-ACL-R, (2) commonly used APA, (3) peer-reviewed primary study with original published data. Study Design: Scoping Review. Level of Evidence: Level 4. Data Extraction: A total of 17 studies included 24 instances of APA with a high degree of heterogeneity for both tests and protocols. Results: Agility makes up 75% of the APA. Only 17.6% of studies reported RTS or reinjury rates, none of which reported a significant relationship between these rates and APA outcomes. Conclusion: Speed, strength, and cardiovascular endurance tests are underrepresented in ACL-R RTS literature. Compared with healthy controls, deficits in APA results for ACL-R athletes were common; however, many studies reported significant improvements in results for ACL-R athletes over time. There is some evidence that well-trained ACL-R athletes can match the performance of uninjured athletes in high-level sports.

Postoperative Return to Play and the Role of Imaging

“…10 16 Although 40 to 60% of athletes may return to the same level of competition following ACL reconstruction, there is a significant risk of injury to the both contralateral and reconstructed ACL when the athlete returns to sport, with up to 19.4% experiencing injury at RTP at 9 months posttreatment and even higher rates with more expedited return to sport. 14…”

“…11 Although this review found a relative minority of studies including metrics of strength (41%), clinical examination (26%), or hop testing (15%) in helping to determine RTP, clinical guidelines support the use of a testing battery to guide RTP timing. 10 11 14…”

“…12,13 ACL injuries are common, occurring at rates of 1 in 50 male and 1 in 36 female athletes throughout the course of a season, with higher female incidence thought to be multifactorial related to ligament size, limb alignment, and muscle strength and activation patterns. 13,14 ACL ruptures often occur in athletes with jumping, cutting, or pivoting, and have high rates in soccer, alpine skiing, handball, wrestling, American football, rugby, and basketball. 13,15,16 Most ACL injuries are noncontact in etiology, with the anteromedial bundle at risk in knee flexion and the posterolateral bundle at risk with hyperextension and internal rotation.…”

“…10,16 Although 40 to 60% of athletes may return to the same level of competition following ACL reconstruction, there is a significant risk of injury to the both contralateral and reconstructed ACL when the athlete returns to sport, with up to 19.4% experiencing injury at RTP at 9 months posttreatment and even higher rates with more expedited return to sport. 14 Management of ACL ruptures is nuanced with variations in surgery timing, graft choice, tunnel placement, reconstruction technique, and rehabilitation impacting the potential postoperative course and imaging appearance. 10 Nonoperative treatment with non-weight-bearing for 6 weeks can allow early participation in sport, but this choice potentially imperils the meniscus and cartilage and typically is only pursued for older or less active patients.…”

“…11 Although this review found a relative minority of studies including metrics of strength (41%), clinical examination (26%), or hop testing (15%) in helping to determine RTP, clinical guidelines support the use of a testing battery to guide RTP timing. 10,11,14 Although no general agreement exists on the ideal battery of clinical tests an athlete must satisfy before RTP, a survey of National Hockey League and Major League Soccer orthopaedic surgeons produced a consensus of 81.8%, recommending at least one clinical test before return to sport, such as the single-leg hop test. 22 The single-leg hop test was further shown to be the single most common functional test used in randomized controlled trials, according to a prior systematic review of examining RTP following ACL reconstruction.…”