Table 5: Progression to Sport-Specific Activities Activity
Criteria for Progression
Action for Failing the Criteria Continue one-to-one opposed sport- specific activity.
Stage 3
One-to-one opposed sport activity Full opponent activity with team
Patients tolerate one-to-one opposed sport-specific activity with no pain or apprehension. Patients are advanced to full opponent activity practice with team.
Stage 4
Note . Reprinted with permission. © 2013, Zakariya Nawasreh.
RETURN-TO-SPORT CRITERIA
One of the approaches to determine patients’ readiness to return to sport is based on the time frame from surgery. Time from sur- gery may account for the graft healing process but not the reso- lution of knee impairments, functional deficits, or limb-to-limb movement asymmetry. Therefore, allowing patients with knee impairments and functional deficits to return to participate in high-demand physical activities solely based upon the time from surgery may result in a negative effect on patients’ outcomes and increase the risk for subsequent injuries. Clinicians may consider both the time from surgery and the resolution of patients’ impair- ments, functional deficits, and movement asymmetry prior to re- turn to activities (Petersen et al., 2014). Recent evidence suggests waiting at least 9 months after ACL reconstruction, and upwards of 12 months or perhaps longer, prior to full participation in jump- ing, cutting, and pivoting sports (Grindem et al., 2016; Nagelli & Hewett, 2017). When patients have a revision or contralateral ACL reconstruction or other high-risk factors for re-injury, clinicians should consider advising an even longer timeframe for return to sport and council the athletes on the relative risks of returning to various types of sports (i.e., level I vs. level II vs. level III). Assessing patients’ readiness after reconstruction surgery is chal- lenging (Ardern, Österberg, et al., 2014). Returning to a preinjury level of activity is a multifactorial in nature and requires multiple aspects of patients’ readiness consideration including the physi- cal, functional, skill-specific, and psychological status. Further- more, it is challenging to identify a set of objective measures that are capable of assessing different aspects of patients’ readiness. Currently, there is no consensus on which set of objective mea- sures constitutes “satisfactory” return-to-activity criteria after sur- gery. Moreover, determining patients’ readiness to return to pre- injury level of activity is not commonly done. In a systemic review study to determine the criteria that have been used to return to unrestricted sport activities after surgery, time from surgery and subjective measures were used in 15% of studies, and objective criteria such as lower extremity muscle strength, limb movement symmetry, knee ROM, and joint effusion were used in only 13% of the studies (Barber-Westin & Noyes, 2011a). Other systematic review studies indicate that there is a lack of objective criteria used to determine return to preinjury sport activity (Ardern et al., 2011b; Barber-Westin & Noyes, 2011b; Harris et al., 2014; Nar- ducci, Waltz, Gorski, Leppla, & Donaldson, 2011; van Melick et al., 2016). Incorporating a comprehensive testing battery using objective measures as criteria may help determine when a patient can more safely return to participate in preinjury activities (van Melick et al., 2016), although no consensus exists on precisely what tests and measures should be included. The commonly used return-to- activity criteria are composed of performance-based tests and pa- tient-reported knee function measures. The combined criteria are used in clinical settings with the attempt to quantitatively assess the limb-to-limb movement, strength, and function performance symmetries and global knee function to determine a patient’s readiness to return to sport after ACL injury and reconstruction surgery (Ardern, Taylor, Feller, & Webster, 2012; Barber-Westin & Noyes, 2011a; Feller & Webster, 2003; Kobayashi et al., 2004; Nawasreh et al., 2016; Petersen et al., 2014; Undheim et al., 2015; Zwolski, Schmitt, Thomas, Hewett, & Paterno, 2016). Using video analysis is also recommended to be used at the time of clearing patients to return to activity for assessing movement quality (Pa-
Patients with an ACL injury are frequently counseled to undergo ACL reconstruction with the expectation of restored mechanical knee stability and normal knee function that facilitates return to their previous levels of sport activities (Marx et al., 2003; Mykle- bust & Bahr, 2005). However, reconstruction surgery does not ensure returning to previous levels of activity and incurring a sec- ond ACL injury is common after surgery (Ardern, Taylor, Feller, & Webster, 2014; Gobbi & Francisco, 2006; Paterno, Rauh, Schmitt, Ford, & Hewett, 2014; Webster & Feller, 2016; Wiggins et al., 2016). After ACL injury and reconstruction surgery, many patients continue to exhibit impaired knee function characterized by dy- namic knee instability, anterior knee pain, joint effusion, reduced ROM, quadriceps strength deficits, reduced functional perfor- mance, neuromuscular dysfunction, and biomechanical maladap- tations that may account for inferior patient outcomes and risk for second injury (Daniel et al., 1994; de Jong et al., 2007; Hartigan et al., 2010; Paterno et al., 2010; von Porat et al., 2004). In patients who are managed operatively, the first several months following surgery are considered the time of greatest vulnerability for those attempting to return to their previous level of activity. Not only are functional performance deficits (Ardern et al., 2011b; Hartigan et al., 2010) and movement asymmetries commonplace (Hartigan et al., 2009; Paterno et al., 2010; Roewer et al., 2011), but reinjury risk is also highest during the first 12 months after ACL reconstruction (Laboute et al., 2010; Paterno et al., 2012; Webster & Feller, 2016; (Grindem et al., 2016). A study by F.W. Smith and colleagues (2004) reported that a group of patients who returned to their level of activity at 1 year after surgery experienced major knee problems in the reconstructed limb. Paterno and colleagues (2014) found that 50% of the second ACL injuries occurred during the first 72 athletic exposures (one athlete participating in one practice or game where the athlete is exposed to the possibility of athletic injury) that included participation in games or practice sessions in a pivoting or cutting sports. This issue might have re- sulted from clearing patients with physical and functional deficits to return high-demand activities, as patients who meet objective functional criteria are at lower risk of subsequent injury (Capin, Snyder-Mackler, et al., 2019; Grindem et al., 2016; Kyritsis et al., 2016). The overall rate of return to preinjury activity level is low and does not meet the expectation after surgery. Only 65% of patients re- turn to their pre- injury sport and only 55% return to their pre- injury level of sport (Ardern et al., 2014). Among those who do return to sport, up to 30% incur a second ACL injury to either the ipsilateral graft or the intact contralateral ACL (Ardern, Taylor, et al., 2014; Hui et al., 2011; Kamath et al., 2014; Leys, Salmon, Waller, Linklater, & Pinczewski, 2012; Paterno et al., 2010; Salmon, Russell, Musgrove, Pinczewski, & Refshauge, 2005; Shelbourne & Muthukaruppan, 2005; Wright, Magnussen, Dunn, & Spindler, 2011(Paterno et al., 2014). Failure to determine patients’ readi- ness at the time of clearing them to return to sport may contribute to the low rate of return to preinjury level of activities and the high rate of second ACL injury. Using a comprehensive set of objective measures as return-to-activity criteria to assess patients’ readiness is crucial for successful outcomes after ACL injury and reconstruc- tion surgery (Capin, Snyder-Mackler, et al., 2019; Grindem et al., 2016; Kyritsis et al., 2016).
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