Does Early Return to Sports Activities Affect Stability After ACL Reconstruction
August 1, 1999 3 minutes read
Does Early Return to Sports Activities Affect Stability After ACL Reconstruction?
Abstract & Commentary
Synopsis: Criteria for allowing an athlete to return to sports vary among surgeons and often lack objective reasoning. This paper examined whether early return to sports had any negative effect on ACL graft stability.
Source: Shelbourne KD, Davis TJ. Evaluation of knee stability before and after participation in a functional sports agility program during rehabilitation after anterior cruciate ligament reconstruction. Am J Sports Med 1999;27:156-161.
Over a six-year period, 603 of 1288 patients with ACL reconstructions met study criteria that included unilateral ACL injury reconstructive surgery, KT-1000 arthrometry examinations before and after returning to sports, no stiffness requiring further procedures, and complete follow-up. Patients were required to have full extension, flexion to 120°, and quadriceps strength of 60% of the opposite leg to begin sports drills. After an initial KT-1000 test, an average of five weeks postoperatively, patients participated in sport-specific agility drills of their choice. The athletes progressed in sports activity as tolerated as long as they did not develop an effusion and maintained their range of motion.
The mean manual maximum side-to-side difference before sports was 1.9 mm. After sports participation at an average of 24 weeks postoperatively, the mean KT-1000 value remained 1.9 mm. No patient suffered a graft failure before the second KT-1000 examination. In fact, over the entire follow-up period for all 1288 ACL reconstructions, only 2.4% of patients had tears of the grafts, compared to 4.3% of patients tearing the opposite-side ACL.
Comment by David R. Diduch, MS, MD
No uniform, objective criteria exist to allow an athlete to return to sports following ACL reconstruction. Studies such as this one by Shelbourne and Davis "push the envelope" in such a way that others can learn. Using criteria of lack of swelling, preserved motion, and at least 60% quadriceps strength, patients were allowed to progress their sports activities. Although the study is vague in terms of how much activity patients were permitted and the types of sports were variable, one can surmise that these patients basically advanced their activities as tolerated as long as they preserved their motion and did not develop an effusion.
It is important to note that all patients had bone-patella-tendon-bone grafts with interference screw fixation by a single experienced surgeon. These results should not be extrapolated to other graft choices, as tendon (hamstring) or allograft does not heal as quickly within the bone tunnels. Although the graft has not been revascularized until closer to one year after surgery (or longer for allografts), the graft and fixation strength for this rehabilitation program appears to be sufficient. Full motion, lack of graft impingement, an adequate notchplasty, and precise tunnel placement are also important factors in their low graft failure rate.
While the study does not advocate unrestricted return to sports at four weeks, the excellent results support an accelerated rehabilitation program that includes some sport-specific drills to help keep the athlete in better form. The study would have been stronger had it been more specific in terms of what sports-specific drills were permitted. Also, it was not clear whether simultaneous meniscal repair altered the protocol. Either way, the rest of us may need to accelerate our rehabilitation protocols now that Shelbourne and Davis have "pushed the limit" a bit more.
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