Systemic Review With Video Illustration
Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction

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Purpose

Anterior cruciate ligament (ACL) reconstruction is commonly performed in athletes, with the goal of return to sports activities. Unfortunately, this operation may fail, and the rates of either reinjuring an ACL-reconstructed knee or sustaining an ACL rupture to the contralateral knee range from 3% to 49%. One problem that exists is a lack of information and consensus regarding the appropriate criteria for releasing patients to unrestricted sports activities postoperatively. The purpose of this study was to determine the published criteria used to allow athletes to return to unrestricted sports activities after ACL reconstruction.

Methods

A systematic search was performed to identify the factors investigators used to determine when return to athletics was allowed after primary ACL reconstruction. Inclusion criteria were English language, publication within the last 10 years, clinical trial, all adult patients, primary ACL reconstruction, original research investigation, and minimum 12 months' follow-up.

Results

Of 716 studies identified, 264 met the inclusion criteria. Of these, 105 (40%) failed to provide any criteria for return to sports after ACL reconstruction. In 84 studies (32%) the amount of time postoperatively was the only criterion provided. In 40 studies (15%) the amount of time along with subjective criteria were given. Only 35 studies (13%) noted objective criteria required for return to athletics. These criteria included muscle strength or thigh circumference (28 studies), general knee examination (15 studies), single-leg hop tests (10 studies), Lachman rating (1 study), and validated questionnaires (1 study).

Conclusions

The results of this systematic review show noteworthy problems and a lack of objective assessment before release to unrestricted sports activities. General recommendations are made for quantification of muscle strength, stability, neuromuscular control, and function in patients who desire to return to athletics after ACL reconstruction, with acknowledgment of the need for continued research in this area.

Level of Evidence

Level IV, systematic review of Level I to IV studies.

Section snippets

Literature Search

We searched Medline for all published literature from April 2001 to April 2011 using the following key words: anterior cruciate ligament reconstruction, ACL reconstruction, ACL reconstruction rehabilitation, and ACL reconstruction results. We also conducted manual searches of the following journals published during this time period: The American Journal of Sports Medicine; Arthroscopy; The Journal of Bone and Joint Surgery (both the American and British volumes); The Knee; Clinical Orthopaedics

Literature Search

Our search initially identified 716 articles, of which 452 were excluded according to our study criteria. This led to 264 articles appropriate for this review. Of these, 105 (40%) failed to provide any criteria for return to sports after ACL reconstruction (Fig 1). In the remaining 159 studies, 6 of the 9 categories of return-to-sports criteria that were searched for were found. The number of categories identified per study was 1 in 125 studies, 2 in 19 studies, 3 in 13 studies, 4 in 1 study,

Discussion

The primary findings of this systematic review suggest that noteworthy problems and a lack of objective assessment methods exist in the published literature before release to unrestricted sports activities after ACL reconstruction. Only 35 (13%) of the 264 articles reviewed included some measurable objective criteria that patients had to achieve before resuming unrestricted athletics. However, even in those articles, only 1 to 2 criteria other than time postoperatively were included in most of

Conclusions

The published literature shows that a lack of consensus regarding the appropriate criteria for releasing patients to unrestricted sports activities exists after ACL reconstruction. A systematic review of the literature was conducted to identify the factors investigators have used over the last 10 years to determine when return to athletics is appropriate. Of 264 studies that met our study inclusion criteria, 105 (40%) failed to provide any measures for return to sports after surgery. Only 35

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    The authors report that they have no conflicts of interest in the authorship and publication of this article.

    Note: To access the video accompanying this report, visit the December issue of Arthroscopy at www.arthroscopyjournal.org.

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