Return to Sport After ACL in the Young Athlete Stephanie Gould Pht, Naudira Stewart P.R.T i000
The ACL epidemic 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 teen boys Incidence of injuries in young athletes : Year-round competition Early specialization Intensive training
Rates of re-injury: Reconstruction Surgery, 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: Not a Magic Pill Only 40-65% return to previous level of sport activity Despite 90% presenting with normal knee function (Stability, ROM and strength)at 6-9mos post
WHY CAN T WE ALL JUST AGREE? How to know if/when a young athlete is 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
Timing isn t everything Time after surgery continues to be the dominant criteria for RTS Recommended time before RTS varies in the literature anywhere 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.
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
Rehab: Weeks 1-4 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 4-12 Closed kinetic chain exercises Progressive hamstring strengthening Quadricep strengtheing with emphasis on Eccentric control Proprioception Core and glute strengthening
Rehab: Weeks 12-24 12 weeks: start training in a gym (including leg press, leg curls) 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
Progressive Sports Training (starting at Month 6 ) Once the athlete has passed the Isokinetic testing with favorable results RTS training begins 1. Running/ sprinting 2. Straight line stops/starts 3. Bilateral Plyometrics 4. Lateral shuffles 5. Running figure-8s 6. Backwards running 7. Cutting/pivoting 8. Closed space agility drills 9. Cariocas 10. Single leg hops (progressing difficulty)
Crucial Factors in RTS (Barber-Westin & Noyes, 2011) 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 A battery of tests is best to assess readiness for return to sport Noyes et al
RETURN TO SPORT Battery of tests 1. Isokinetic testing 2. Knee ROM, effusion, stability tests 3. 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 agility 7. Validated patient-reported outcome measures A. IKDC B. ACL-RSI
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 Test L.E.F.T
7. Validated Questionnaires 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)
But wait 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 complete games
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 continued strength training
Conclusion When can I go back to my sport? When you can demonstrate that you are ready!
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.
REFERENCES 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.
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