Return to Sport after ACL Reconstruction

Sara CordellIthaca College

Protocol timeline Concomitant injuries or complications Knee stability and strength Objective vs. subjective data Reliability, validity, accuracy, functional

relevance of tests Individual circumstances, fears, values,

motivation, etc Demands of particular sport(s) Clinical experience/judgment

Challenge of Deciding Return to Sport

Many Factors Involved

≥90% symmetry between involved and uninvolved sides for objective testing (isokinetic testing, hop testing, etc)

Full, nonpainful ROM No joint effusion Joint stability- KT test ≤3mm side-to-side

difference MD and PT opinions

General Return to Sport Guidelines

Return to Sport Algorithm According to Myer et al.

Biodex Isokinetic Testing KT Testing Agility testing- Modified T-test Balance testing- Stabilometer Goniometry to measure symmetry of

movement Compare symmetry of GRFs Deceleration testing Hop testing

Objective Testing Options

Common tests- single leg hop for distance, 6m timed hop, triple hop for distance, crossover hops for distance

Limb symmetry index (LSI=involved/uninvolved x100% for distance measures, opposite for time)

Begun ~12-16weeks post-op Pros- test many aspects of LE movement at

once, time efficient, minimal equipment Cons- learning curve, functional relevance,

don’t address quality of movement, measurement error

Hop Testing

Hops in Reid et al.

Characteristics of Hop Tests Test Reliability (ICC) MDC (%)

Single hop .92 8.09

6m timed hop .82 12.96

Triple hop .88 10.02

Crossover hop .84 12.25

Overall combination .93 7.05

Four tests together- sensitivity= 82%Single hop test alone- sensitivity= 38-52%

Vertical jump Single hop for

distance Drop jump followed

by double hop Square hop Side hop

Hops in Gustavsson et al.

Hop Test Evaluation

Statistic Vertical jump

Hop for distance

Drop jump w/ double hop

Square hop

Side hop

Sensitivity 86 63 63 51 69

Specificity 87 100 100 67 87

Accuracy 86 74 74 56 74

Vertical jump, single hop for distance, side hop

Sensitivity: 91% for identifying patient as abnormal when at least 1 of the 3 tests was abnormal

Accuracy: 84% for truly normal subjects and 88% for truly abnormal subjects

Hop Test Battery

54% had abnormal LSI in ALL 3 tests 91% had an abnormal value in at least one

of the 3 tests Only 9% had all normal LSI values

At 6 months post-op…

Patient Example

Test *Left Right LSI

Single Hop 1.48m 1.62m 91.3%

Vertical Jump

10.43in 13.03in 80.0%

Side Hop 34in 49in 69.3%

Test *Left Right LSI

Single Hop 1.48m 1.62m 91.3%

6m Hop 2.5s 2.63s 105.2%

Triple Hop 4.72m 4.82m 97.9%

Crossover Hop

4.1m 4.8m 85.4%

Reid Test Battery

Gustavsson Test Battery

Augustsson et al. evaluated effect of fatigue on single hop testing results

Fatigue- repeat as many reps as possible at 50% 1RM

All patients included in study had ≥90% symmetry in non-fatigued conditions

After pre-exhaustion exercise, 68% demonstrated abnormal hop symmetry

Effect of Testing in Fatigued State

Do not use only one or two testing methods Consider whole athlete and demands of

sport Reference protocol timeline but also use

functional goals as criteria for progression No objective tests are perfect, supplement

with clinical judgment and experience Consider testing athlete in non-fatigued and

fatigued conditions

Take Home Messages

Criteria based algorithm as proposed by Myer?

Can you identify the most important factors when deciding return to sport?

Most clinically useful objective measures? Most reliable/valid hop tests? Testing in fatigued vs. non-fatigued state? Commonly overlooked factors?

What is your opinion?

Augustsson J, Thomeé R, Karlsson J. Ability of a new hop test to determine functional deficits after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. Sept 2004;12(5):350-356.

Gustavsson A, Neeter C, Karlsson J, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA. August 2006;14(8):778-788.

Hartigan EH, Axe MJ, Snyder-Mackler L. Time line for noncopers to pass return-to-sports criteria after anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2010; 40: 141-154.

Kvist J. Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Medicine. 2004;34(4):269-280.

Myer G, Paterno M, Ford K, Quatman C, Hewett T. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase. The Journal Of Orthopaedic And Sports Physical Therapy. June 2006;36(6):385-402.

Reid A, Birmingham T, Stratford P, Alcock G, Giffin J. Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy . March 2007;87(3):337-349.

References