The Association Between Passing Return-to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Meta-analysis

Abstract

Background There is no consensus on the components of return-to-sport (RTS) testing following anterior cruciate ligament (ACL) reconstruction or whether passing RTS criteria can reduce a patient's risk of reinjury. Objectives To determine whether impartial, criteria-based RTS decisions are associated with less risk of a second ACL injury (either graft failure or contralateral ACL injury). Methods In this systematic review with meta-analysis, the authors conducted an electronic literature search in PubMed/MEDLINE, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses Global using database-specific vocabulary related to ACL reconstruction and return to sport. Individual study quality was assessed using the modified Downs and Black checklist, and overall quality of evidence was determined with the Grading of Recommendations Assessment, Development and Evaluation scale. Pooled risk difference (passed versus failed RTS criteria), injury incidence proportion, and the diagnostic accuracy of each RTS criterion were calculated. Results Four studies met the selection criteria. Overall, 42.7% (95% confidence interval [CI]: 18%, 69%) of patients passed RTS criteria, and 14.4% (95% CI: 8%, 21%) of those who passed experienced a second ACL injury (graft rupture or contralateral ACL injury). There was a nonsignificant 3% reduced risk of a second ACL injury after passing RTS criteria (risk difference, −3%; 95% CI: −16%, 10%; I2 = 74%, P = .610). The evidence rating of the Grading of Recommendations Assessment, Development and Evaluation scale was “very low quality,” due to imprecision and heterogeneity of the pooled risk difference estimate. Conclusion Passing RTS criteria did not show a statistically significant association with risk of a second ACL injury. The quality-of-evidence rating prevents a definitive conclusion on this question and indicates an opportunity for future research. Level of Evidence Prognosis, Level 2a-. J Orthop Sports Phys Ther 2019;49(2):43–54. Epub 30 Nov 2018. doi:10.2519/jospt.2019.8190

How should clinicians rehabilitate patients after ACL reconstruction? A systematic review of clinical practice guidelines (CPGs) with a focus on quality appraisal (AGREE II)

“…Criteria for when to let the athletes progress are not standardised and experts disagree on the choice of follow-up patient-reported and physical performance-based outcome measures 19 20. There is no agreement on the key criteria that should be met before return to sport 11 21–23…”

Better reporting standards are needed to enhance the quality of hop testing in the setting of ACL return to sport decisions: a narrative review

“…3 However, hop and isokinetic tests do not consistently predict successful outcomes following ACL rehabilitation. Losciale et al 4 reported no associations between the use of RTS discharge tests and greater risk of reinjury, stating the low quality of evidence affects our ability to make definitive conclusions. Toole et al 5 reported that many young athletes had been cleared to RTS by their surgeon and rehabilitation specialist but failed to pass the RTS cut-offs cited in the literature.…”

Uninjured Youth Athlete Performance on Single-Leg Hop Testing: How Many Can Achieve Recommended Return-to-Sport Criterion?

“…9,12,13,25 The battery of hop tests used within the present study have demonstrated good discriminative accuracy and predictive abilities 7,24,32 ; however, the clinical utility of these and other commonly utilized return-to-sports assessment methods have recently been questioned due to a lack of association with secondary ACL injury risk. 26,27,34,42 In addition, several reports have identified that many athletes cleared to return to sports after ACLR are unable to achieve the contemporary standard of ≥90% LSI, 11,14,27,39 further challenging the clinical utility of these measures and raising concerns about the validity of the 90% LSI criteria to which post-ACLR athletes are held.…”