The ACL-Deficient Knee by Vicente Sanchis-Alfonso & Joan Carles Monllau

Author:Vicente Sanchis-Alfonso & Joan Carles Monllau
Language: eng
Format: epub
Publisher: Springer London, London

15.4.2 When Are Patients Likely to Have Sufficient Strength and Neuromuscular Control to Cope with the Physical Demands of Their Sport?

Many clinical guidelines and test batteries exist regarding the criteria that must be met before a patient is cleared to return to sport after surgery. However, while these protocols have been extensively researched and validated and the theory behind them justified, the evidence to support their actual predictive value for a safe return to sport has not been as extensively explored. While many authors recommend patients achieve a certain predetermined functional level before being considered ready to return to sport, it seems that evidence is lacking to demonstrate that patients who meet the chosen criteria actually make a ­successful and safe return to their sport. Similarly, it is unclear whether patients who fall short of the return-to-sport criteria do in fact successfully return to sport despite their apparent functional limitations.

It is often assumed that adequate knee stability is important before returning the athlete to sport. However, instrumented measures of anterior knee laxity taken while the patient is resting have been shown not to correlate with function [18]. It is also important to consider the relevance of static anterior laxity measures to the rotational as well as the dynamic nature of knee function required for sports participation. An accurate and readily available tool for measurement of either rotational laxity or dynamic function is not presently available.

Other objective measures used to guide return-to-sport decision-making include hop tests and isokinetic muscle strength tests. The IKDC suggests a side-to-side difference of less than 10 % in hop testing qualifies the knee as “normal.” Kvist [18] recommended that the side-to-side difference in hamstring and quadriceps isokinetic muscle strength should not exceed 15 % at the time of return to sport. Although such measures are widely reported in clinical follow-up studies, their use as indicators of readiness for return to sports participation may be questioned. Two recent studies have shown conflicting evidence regarding whether IKDC objective outcomes or hop tests differ between athletes who do and do not return to their pre-injury level of sport by 12 months [3, 21].

As the use of objective measures suggest, many authors prefer a goal-oriented approach to rehabilitation progression rather than a time-based progression. An example of this is Shelbourne and Nitz [32], who based their rehabilitation progression on the recovery of strength in the operated limb. Patients completing their accelerated program were permitted to return to light sport as early as 8 weeks postoperatively, provided the strength of the operated limb exceeded 70 % of the nonoperated limb in isokinetic testing, and the patient had completed sport-specific agility training.

Myer et al. [22] published a detailed clinical algorithm for return to sport following ACL reconstruction surgery. The four-stage rehabilitation process emphasized minimizing side-to-side differences in biomechanics of landing, agility, and sport-specific tasks to minimize the chance of re-injury following return to sport. The protocol emphasized the importance of restoring symmetrical neuromuscular control prior to allowing the athlete to commence preparation for returning to full competition.

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