Return to sport testing after ACL rupture
Australia has the highest reported rates of Anterior Cruciate Ligament (ACL) ruptures in the world (Zbrojkiewicz, Vertullo, & Grayson, 2018). With the majority of these ruptures occurring within a sporting environment it’s not unusual that the first question a patient asks is “when can I get back to sport?”. Regardless of whether a patient has undergone surgery or not there are strict criteria that need to be met before progressing to sport.
The Melbourne ACL Rehabilitation Guide (Cooper & Hughes, 2018) is a widely accepted framework put in place to return to sport after an ACL rupture. The ACL rehabilitation protocol is broken down into 6 phases, with a list of goals and outcome measures that need to be satisfied at the end of each phase to move onto the next one.
The six phases are:
- Pre-op Phase: Injury recovery & readiness for surgery
- Phase 1: Recovery from surgery
- Phase 2: Strength & neuromuscular control
- Phase 3: Running, agility, and landings
- Phase 4: Return to sport
- Phase 5: Prevention of re-injury
The first three stages of the guide are relatively straight forward with the main goals being to reduce swelling, increase movement, increase strength and increase function. These phases are targeted through a home exercise program as well as supervised exercise sessions and progressed by meeting strength and mobility goals.
The final phases of the protocol continue to build on the strength foundation by further developing the knee to propel and stabalise during running, jumping and changing direction. Some key criteria that need to be addressed to progress from stage 3 to stage 4 are single and triple hop test, side hop test and dynamic balance.
As the names suggest, the single and triple hop test are measuring the distance travelled on the affected leg with one and three hops respectively. In addition to comparing the distance travelled to the non affected leg, the overall quality of the hops are assessed. When looking at the quality of the hops it is important to pay attention to the muscle groups and techniques generating the force as well as the absorption of force on landing.
The side hop test compares the affected and non affected leg hopping sideways across a 40cm distance. Similar to the other hop tests the quality of the hops are taken into account in addition to the volume of hops achieved in 30 seconds.
The last key passing criteria is the dynamic balance assessment. These assessments ensure the leg’s ability to distribute weight, enabling the body to remain upright and steady during reaching tasks as well as when the opportunity for visual fixation is removed.
To progress to phase 4 the results of the above criteria need to be within 95% of the non affected leg.
Once the leg is within 95% functionality of the non affected leg and the patient is ready to return to sport The Melbourne Return to Sport Score is completed. The Melbourne Return to Sport Score is an assessment tool for return to sport following anterior cruciate ligament reconstruction. There are three components to the test:
- Clinical Examination (25 marks)
- IKDC Subjective Knee Evaluation (25 marks)
- Functional Testing (50 marks)
People receive a score out of 100, with a score of more than 95 indicates a greater chance of returning to pre-injury sports and in the short term.
Once all return to sports hurdles have been completed then a gradual return to sport can occur. It is important to note that the return to sport needs to be staggered and can not happen all at once.
An example of returning to sport could be as follows:
- Conditioning and basic skill training
- Light training as offensive
- Full training as offensive
- Defensive training
- Full unrestricted training
- Lower level sports competition
- Pre injury level sports competition
So when will I be back to sport?
The modern return to sport models are focused on meeting objectives as opposed to meeting time frames. Having said this, a highly motivated patient is likely to progress through the program and return to sport around the 9-10 month mark. A study reported a reduction by 51% for each month return to sport was delayed until 9 months after surgery. Delaying return to sport to 9 months gives sufficient time to recondition the body and allow it to adapt to all sport-specific drills necessary to avoid instability and future re-injury (Grindem et al., 2016).
Unfortunately once return to sport is completed it does not mean you are out of the woods.
The incidence of re-injury in the first two years following reconstruction is estimated to be 6 times greater than those who didn’t suffer ACL injury. Studies have reported 29.5% ACL re-injury in the second year with 20% sustaining injury to the other leg (Paterno et al., 2014). This risk of re-injury can extend up to 6 years following injury with research showing 25% of athletes undergo a second revision within 6 years of the original ACL surgery (Battaglia et al., 2007).
Furthermore, studies have estimated an 84% reduction of knee re-injury rates in patients who pass the return to sport criteria as opposed to those who drop out (Grindem et al., 2016).
The bottom line:
- Initial recovery from surgery focuses to reduce swelling, increase movement, increase strength and increase function.
- Once basic strength is mastered running and change of direction can be added
- Recovering from an ACL rupture takes AT LEAST nine months, early return to sport increases the rate of re-injury
- Committing to the full rehabilitation program can reduce the risk of re-injury by 84%
Battaglia, M., Cordasco, F., Hannafin, J., Rodeo, S., O’Brien, S., & Altchek, D. et al. (2007). Results of Revision Anterior Cruciate Ligament Surgery. The American Journal Of Sports Medicine, 35(12), 2057-2066. https://doi.org/10.1177/0363546507307391
Cooper, R., & Hughes, M. (2018). Melbourne ACL Rehabilitation Guide 2.0. Retrieved August 10, 2022, from https://www.melbourneaclguide.com/
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal Of Sports Medicine, 50(13), 804-808. https://doi.org/10.1136/bjsports-2016-096031
Paterno, M., Rauh, M., Schmitt, L., Ford, K., & Hewett, T. (2014). Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. The American Journal Of Sports Medicine, 42(7), 1567-1573. https://doi.org/10.1177/0363546514530088
Zbrojkiewicz, D., Vertullo, C., & Grayson, J. E. (2018). Increasing rates of anterior cruciate ligament reconstruction in Young Australians, 2000–2015. Medical Journal of Australia, 208(8), 354-358. doi:10.5694/mja17.00974