How Soon Do Athletes Really Return to Sports After Anterior Cruciate Ligament Surgery?

The timeline currently used for athletes after anterior cruciate ligament (ACL) surgery goes something like this. Rehab and recovery after surgery takes a good four to six months for everyone. Sports specific training is designed to return athletes to their sport by the end of a year's time.

But can they participate at their preinjury level? Are most athletes really back on the field, court, or track by the end of 12 months? That's what this study was all about. It was conducted at the Musculoskeletal Research Centre at the La Trobe University in Australia.

The researchers took a look at data collected on over 500 competitive athletes who had surgery to reconstruct a torn anterior cruciate ligament (ACL). One surgeon did all of the surgeries. All patients included in the study had the procedure done arthroscopically with a single-incision. The tendon graft used was taken from the patient's hamstring muscle (tendon). The harvested tendon tissue was looped over to form a quadruple-strand graft.

The goal of surgery was to restore joint stability. In practical terms, this means getting the athlete back to activities that involve jumping, pivoting, and cutting. In this study, patients were Australian football, basketball, netball, or soccer players.

They also analyzed the results to see if there were any specific factors that could predict who would do well and how soon athletes did, indeed, return to their sports participation.

Some of the items reviewed included 1) whether the athlete was engaged in seasonal versus year-round sports, 2) how soon the surgery was done after the injury, and 3) whether sex (male versus female) made a difference. In other words, were men or women more likely to return-to-sports before the end of the first year?

Patients were contacted after the end of a full 12-months following surgery. They were asked if they had returned-to-sport (or attempted to return) and their current playing status. If they had not yet returned-to-sport, they were asked why not and if they intended to return (and how soon).

Specific tests of knee function were also performed and results compared from before surgery to after surgery. Two of the tests used included the Cincinnati Sports Activity Scale (SAS) and the International Knee Documentation Committee (IKDC) evaluation.

Two thirds of the 503 athletes had not attempted participating fully in competitive sports at the time of follow-up. About half of those 335 athletes had attempted training and/or modified competition. Most of these folks were male. The other half (some men but mostly women) had made no attempt at sports activity.

Some patients had given up because of the knee problems. An equal number gave up sports for other reasons. A large number (159 patients -- an equal number of men and women) still planned to return to competitive sports but 84 had no intention of doing so.

Taking a look at the test scores, it was clear that about half of the patients (48 per cent) had normal knees. The other half (actually 45 per cent) had nearly normal knees. The remaining seven per cent had abnormal (some severely abnormal) knee function.

Athletes engaged in seasonal sports were more likely to get back into the game. The break between seasons gave them more time to rehab and recover compared with athletes who played year-round with no breaks.

The results of this study showed the expectation of return-to-sports within 12 months of ACL surgery may not be realistic. For a competitive athlete who decides to have this procedure thinking he or she will get back to sports sooner, this information is very important.

The authors note that using the preinjury level of participation as the key measure may be somewhat restrictive but it is a more accurate reflection of real life for athletes. They go into surgery thinking and hoping that they will be able to return to their sport fully but end up with a reduced level of playing ability. Some return to play but in a different sport -- perhaps one that doesn't involve pivoting, sudden twists and turns, or jump-land maneuvers.

One other difference from this study to others was the timing of return-to-sport. The earliest patients in this study were allowed back on the field was nine months after surgery. In other studies, athletes return as early as six months. It may seem like they do better getting back earlier but the studies don't always use the preinjury level of participation as their measuring stick.

More study is needed to clear up some of these differences before we will know for sure. For now, it looks like many athletes may need more than the traditional six to 12-month break from sports after ACL reconstruction.

A longer period of rehab may be needed to truly get back to full sports play with no restrictions. Women may need more time than men despite their intentions to return to full function in 12 months. There may be other reasons athletes don't return to their sport such as fear of reinjury. Psychologic factors of this type were not investigated in this study but may need a closer look in the future.

Reference: Clare L. Ardern, PT, et al. Return to the Preinjury Level of Competitive Sports After Anterior Cruciate Ligament Reconstruction Surgery. In The American Journal of Sports Medicine. March 2011. Vol. 39. No. 3. Pp. 538-543.

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