Injury Management Decision Making. Elizabeth A. Arendt, M.D. 3 Elements to Consider in return to Activity. Healing Six Months.

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1 Page 1 of 5 Return to Play : How to Evaluate?? What guides our decisions?? Injury Management Decision Making Informed Consent Professor and Vice Chair Dept of Orthopedics, U of Minnesota, USA Medical Director of Intercollegiate Athletics Does the MD know the risk of play vs. no play? Is there enough Science to make Informed decisions? At what age does one assume informed consent? I have no conflict of interest to declare Multiple Stake Holders Athlete Team MD ego Institution Parents Decisions are very individualized By patient profile and by MD!!! Does this change with individual factors? Short term risks Can the injury get worse? Injury Management Can injury lead to permanent sequelae? Long term risk Benefits to return to play Who benefits? Spectrums of Decision Making Creighton et al., Clin. J. Sports Med. 20: , 2010 Creighton et al., Clin. J. Sports Med. 20: , Elements to Consider in return to Activity Biology of healing Functional Capacity Strength / Agility / Co-ordination Body movement patterns Mental readiness to return to sport Healing Six Months

2 Page 2 of 5 Healing Nine Months Original Items in the ACL Return to Sport After Injury Scale Scale Item Order Mean in Scale (S.D.) Emotions 1. Are you nervous about playing your sport? (30) 2. Do you find it frustrating to have to consider your knee with respect to your sport? a (34) 3. Do you feel relaxed about playing your sport? (26) 4. Are you fearful of re-injuring your knee by playing your sport? (29) 5. Are you afraid of accidentally injuring your knee by playing your sport? (28) Confidence in performance 6. Are you confident that your knee will not give way by playing your sport? (27) 7. Are you confident that you could play your sport without concern for your knee? (29) 8. Are your confident about your knee holding up under pressure? (26) 9. Are you confident that you can perform at your previous level of sport participation? (25) 10. Are you confident about your ability to perform well at your sport? (25) Risk appraisal 11. Do you think you are likely to re-injure your knee by participating in your sport? (25) 12. Do thoughts of having to go through surgery and rehabilitation again prevent you from playing your sport? (30) a Item 2 was from the Quality of Life Outcome Measure for Chronic ACL Deficiency (ACL-QOL) scale (Mohtadi, 1998). Quality of Life (Mohtadi 1998) Social and Emotional The following questions are about your attitudes and feelings as they relate to your ACL-deficient knee. 27. Does it concern you that your competitive needs are no longer being met because of your knee problem? (Make a slash at the extreme right, i.e., 100, if your competitive needs are being met.) Not concerned concerned 28. Have you had difficulty being able to psychologically come to grips with your knee problem? Not difficult difficult 29. How often are you apprehensive about your knee? All of the None of the time time 30. How much are you troubled with lack of confidence in your knee? Severely No trouble troubled 31. How fearful are you of reinjuring your knee? No fear fearful Return To Pre-injury Level Competition Sport After ACL Reconstruction The cohort n=503 competitive athletes. Male 68%. Female 32%. Mean Age 27+/- 8 years. Clinical eval 93%: normal or nearly normal IKDC 84% had a hop test symmetry of >/=85% High Function on hop test more likely to return to sports than patients with normal postoperative knee function by IKDC clinical category. Males more likely to return to competitive sports than females Feller et al., AJSM, 2011 Self-Efficacy Scale (K-SES) D. Your knee function in the future (1) How certain are you that you can return to the same physical activity level as before the injury? (2) How certain are you that you would not suffer any new injuries to your knee? (3) How certain are you that your knee will not break? (4) How certain are you that your knee will not get worse than before surgery? (for those of you who underwent surgery) Thomeé et al., Scan. J. Med. & Science in Sports 16: , 2006 Return To Pre-injury Level Competition Sport After ACL Reconstruction Patients with a higher fear of re-injury less likely to have returned to their pre-injury level of sports participation Feller et al., AJSM, 2011 Kvist et al., KSST 2005 Tripp et al., Rehab. Psych Emotional Response Of Athletes To Injury Questionnaire (EIQ) A questionnaire built to assess an athlete s response to injury Frustration and anger were the most strongly experienced emotions. Families and teammates were the most important source of social support during recovery Rehab Progression CORE Double leg mechanics Single leg mechanics Body movement patterns Dynamic activities Sport specific activity Klenk, 2006

3 Page 3 of 5 Physical Therapy Progression CORE Double stance Single leg Dynamic activities Physical Therapy Progression CORE Double stance Single leg partial squats Dynamic activities 2 Legged Squat: Symmetrical WB (over scales) Gluteal Activation (band resistance) Examining Double Leg Mechanics Excessive anterior knee excursion Normal (note hamstring firing) Examining Single Leg Mechanics Dynamic Activites Functional valgus Femoral IR Hip substitution Pelvic drop Hips level Knee over toes with flexion Control into full extension Pelvis level Dynamic Activities Physical Performance Testing

4 Page 4 of 5 Existing Validated Measures of Functional Limb Performance Single Leg Hop for Distance 6M Timed Hop Triple Hop for Distance Triple Cross-over Hop for Distance Bolgla LA. JOSPT 1997 Greenberger HB. JOSPT 1995 Single-Limb Single Hop Test for Distance Description: distance a travels w/a single hop on 1 limb Nature of variable: Continuous Units of measurement: Centimeters Measurement properties: Healthy individuals: Mean distance: Test-retest reliability ICC = 0.92, SEM = 4.61 cm, cm LSI reliability in patients with ACL reconstruction ICC = 0.92 Range of mean LSI 16 wks post-aclr= 81.0%-82.9% Mean LSI at 22 weeks post-acl reconstruction = 88.2% Single-Leg Hop Single Leg Squat Demonstrates leg strength and pelvic symmetry Quantitative measurement of knee flexion Qualitative assessment of form and controlled motion Quantitative measurement of distance Targets quad & hip extensor strength Qualitative assessment of hip/knee alignment, pelvic symmetry Quantitative measurement of step height. Retro Step-up Qualitative assessment of body motion Balance Single Leg Reach Test Demonstrates balance & strength with sagittal plane motions Quantitative Measure distance reached Qualitative assessment of body motion Balance: SEBT Star Excursion Balance Test Anterior Reach Posterolateral Reach Posteromedial Reach Star Excursion Balance Test Composite Score = {[(A+PM+PL)]/(LL x 3)] x 100 A = max. anterior reach PM = max. posteromedial reach PL = max. posterolateral reach LL = limb length 45 45

5 Page 5 of 5 3 Elements to Consider in return to Activity Biology of healing Functional Capacity Strength / Agility / Co-ordination Body movement patterns Mental readiness to return to sport Case Example Thank You