When can I return to sport after ACL injury?
Peter Wallace
Competed for 2 years with the Penrith Panthers without an ACL
Return to sport time-frames vary widely depending on the type of sport, pre-injury level of sport, type and number of injuries sustained, and the type of intervention performed.
Knowing when it is safe and appropriate to return to training and competition is critical in making the transition back into sport.
Unfortunately, not everyone will return to pre-injury level of sport, and some may not return to sport at all. A systematic review of 69 studies with 7556 participants found only 55% on average return to competitive sport following ACL reconstruction, 65% return to pre-injury level and on average 81% return to any sport (Ardern, 2014).
For those that don’t have surgery, return to sport timeframes are on average between 3-6 months, with some elite athletes returning in as little as 8 weeks post-injury (Frobell, 2013; Weiler, 2015).
Neither surgery or no surgery seem to increase the chances of returning to sport at pre-injury level (Filbay, 2015; Frobell, 2013; Myklebust, 2003; Roos, 1995). What most likely matters is the quality of rehabilitation (Culvenor, 2018).
So how do you know when you are ready to return to sport?
There are several criteria that need to be met before returning to sports, particularly sports involving pivoting, jumping, or cutting movements such as Football, NFL, NRL, AFL, Tennis, Skiing, Surfing etc.
Passing return to sports criteria is essential to reducing the risk of reinjury. Passing all return to sport criteria reduced the risk of reinjury by up to 92% (Grindem, 2020).
Being psychologically ready to return to sport is a significant factor in determining readiness to return. Lack of confidence and fear pose an increased risk of reinjury and less likelihood of successfully returning to sport (Ardern, 2014; McPherson, 2019; Paterno, 2018).
For those who have had surgery, waiting at least 12 months post-op before returning to level 1 pivoting sports (Football, AFL, NFL etc.) is a key factor in reducing re-injury risk, those who return to sport before 12 months pose up to a 6x greater risk of second ACL injury compared to those who wait at least 12 months before returning (Grindem, 2020).
What are the return to sport discharge criteria?
· At least 90% maximum voluntary isometric quadriceps strength compared to the uninjured limb
· At least 90% maximum voluntary isometric hamstring strength compared to the uninjured limb
· At least 90% limb symmetry on hop testing battery (Grindem, 2016; Kryitsis, 2016)
· Score at least 76.6 on the ACL Return to Sport After Injury Scale (ACL-RSI)
· Score less than 19 on the Tampa Scale-11 (TSK-11)
· Wait at least 12 months post-operatively (surgical patients only)
· Complete at least 4 weeks of unrestricted training prior to returning to competition (recommendation)
If you do not complete or pass these discharge criteria prior to returning to sport, you are at significantly greater risk of second injury.
For those who have not had surgery, I recommend, based on the best available evidence, to complete at least 12 weeks of neuromuscular rehabilitation exercise prior to returning to pivoting sports.
References:
Ardern, C. L., Taylor, N. F., Feller, J. A., & Webster, K. E. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med, 48(21), 1543-1552.
Frobell, R. B., Roos, H. P., Roos, E. M., Roemer, F. W., Ranstam, J., & Lohmander, L. S. (2013). Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Bmj, 346, f232.
Weiler, R., Monte-Colombo, M., Mitchell, A., & Haddad, F. (2015). Non-operative management of a complete anterior cruciate ligament injury in an English Premier League football player with return to play in less than 8 weeks: applying common sense in the absence of evidence. Case Reports, 2015, bcr2014208012.
Filbay, S. R., Culvenor, A. G., Ackerman, I. N., Russell, T. G., & Crossley, K. M. (2015). Quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis. British journal of sports medicine, 49(16), 1033-1041.
Myklebust, G., Holm, I., Mæhlum, S., Engebretsen, L., & Bahr, R. (2003). Clinical, functional, and radiologic outcome in team handball players 6 to 11 years after anterior cruciate ligament injury: a follow-up study. The American journal of sports medicine, 31(6), 981-989.
Roos, H., Ornell, M., Gärdsell, P., Lohmander, L., & Lindstrand, A. (1995). Soccer after anterior cruciate ligament injury—an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players. Acta orthopaedica Scandinavica, 66(2), 107-112.
Culvenor AG, Barton CJ. ACL injuries: the secret probably lies in optimising rehabilitation. British Journal of Sports Medicine 2018;52: 1416-1418.
Grindem, H., Engebretsen, L., Axe, M., Snyder-Mackler, L., & Risberg, M. A. (2020). Activity and functional readiness, not age, are the critical factors for second anterior cruciate ligament injury—the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine.
McPherson, A. L., Feller, J. A., Hewett, T. E., & Webster, K. E. (2019). Psychological readiness to return to sport is associated with second anterior cruciate ligament injuries. The American journal of sports medicine, 47(4), 857-862.
Paterno, M. V., Flynn, K., Thomas, S., & Schmitt, L. C. (2018). Self-reported fear predicts functional performance and second ACL injury after ACL reconstruction and return to sport: a pilot study. Sports health, 10(3), 228-233.
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (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.
Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., & Witvrouw, E. (2016). Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British journal of sports medicine, 50(15), 946-951.
