SLIDE 1 Return to Sports after ACLR: Objective Test Criteria You Must Pass to Play
Mark V. Paterno PT, PhD, MBA, SCS
Coordinator of Orthopaedic and Sports Physical Therapy Scientific Director, Division of Occupational Therapy and Physical Therapy Cincinnati Children’s Hospital Medical Center Professor, Division of Sports Medicine, Department of Pediatrics University of Cincinnati College of Medicine
SLIDE 2 Why is this an important topic?
- 1. Currently our criteria to return an athlete to
sport are not well defined.
- 2. Athletes may be returning to sport
prematurely, at high risk
- 3. Athletes may be restricted from returning
to sport based on irrelevant variables
- 4. Forces us as clinicians to rely on the
art, rather than the science of medicine.
SLIDE 3 CLINICAL QUESTION: When is it safe to return to sports after ACLR?
1. What is “safe”? 2. When is it physically possible to return?
SLIDE 4
SLIDE 5 Discussion: Crude Incidence
Injury Prop. Follow Up Paterno at al 2012 23.6% 1 year Paterno et al 2014 29.5% 2 year Wright et al 2007 6% 2 year Wright et al 2011 17.2% 5 year Pinczewski et al 2007 27% 10 year
SLIDE 6
Return to Sports Rates
SLIDE 7
ACL Return to Sport: Systematic Review
Kvist J. “Rehabilitation Following Anterior Cruciate Ligament Injury: Current Recommendations for Sports Participation.” Sports Med 2004: 34(4): 269-280.
34 articles between 1998-2003
SLIDE 8 Current Criteria for Return to Sport
Outline of criteria reported:
- 13/34 assessed isokinetic strength
- 25/34 used jump testing
- 14/34 reported some clinical criteria (i.e. ROM,
knee stability etc.)
- 4/34 had no assessment of strength or
performance
Kvist J. Sports Med 2004
SLIDE 9 Current Criteria for Return to Sport Kvist 2004
- Systematic Review (n=34)
- 1/3 : isokinetic testing
- 2/3 : functional hop testing
Barber-Westin et al 2011
- Systematic Review (n=264)
- 40% : no criteria
- 13% : objective criteria
SLIDE 10 Current Return to Sport Measures
1. Time from surgery 2. Strength 3. Knee laxity 4. Functional Performance Testing 5. Patient reported outcomes
SLIDE 11 Return to Sport Assessment
“…low correlations between various hop test scores and self-reported measures of function may indicate that neither of these methods can stand alone as an adequate assessment of knee function.”
Fitzgerald GK et al “Hop Tests as Predictors of Dynamic Knee Stability” JOSPT 2001
SLIDE 12 Current Criteria
Grindem et al BJSM 2016
- Failing to pass all D/C criteria at 90 or greater
increased risk of re-injury
- Included, but not limited to ACL injury
Kyritsis et al BJSM 2016
- Failing to meet all D/C criteria = 4 times
greater risk of graft rupture
- Cohort included male professional soccer
players
SLIDE 13 ACL Return to Sport: What is Missing?
– Balance and Proprioception – Strength – Functional hop testing
– Bilateral Asymmetries
– Altered movement patterns
– Fear – Confidence
SLIDE 14
Biomechanical Measures during Landing and Postural Stability Predict Second Anterior Cruciate Ligament Injury after ACL Reconstruction and Return to Sport
Mark V. Paterno PT, PhD, SCS Laura C. Schmitt PT, PhD Kevin R. Ford PhD Mitchell J. Rauh PT, PhD, MPH, FACSM Gregory D. Myer MS, CSCS Bin Huang PhD Timothy E. Hewett PhD, FACSM
AJSM 2010
SLIDE 15
Results: Hip Rotation Net Moment Impulse (Initial 10% of landing)
SLIDE 16
Results: 2D Frontal Plane Knee Kinematics
SLIDE 17
Results: Sagittal Plane Moment at Initial Contact
SLIDE 18
Results: Postural Stability
SLIDE 19 Results: Predictive Model
Area under ROC = 0.94 (Sensitivity = 0.92, Specificity = 0.88) Area under ROC (hip imp. only) = 0.81 (Sen=0.77,Spec = 0.81)
SLIDE 20
Clinical Factors Predict Second ACL Injury after ACL Reconstruction and Return to Sport: Development of a Clinical Decision Rule
Mark V. Paterno PT, PhD, SCS Bin Huang PhD Staci Thomas MS Tim E. Hewett PhD Laura C. Schmitt PT, PhD OJSM 2018
SLIDE 21 Results
Profile Risk Initial Cohort
N=114 High Risk (22/53) 41.5% Profile 1 (19/43) 44% Profile 2 (3/10) 30% Low Risk (1/61) 1.6%
SLIDE 22 Results
High Risk Profile 1 High Risk Profile 2
- Young (<19 y/o)
- Young (<19 y/o)
- TrH Normalized to Height
(1.34-1.90 X BH)
(>1.34 X BH)
(<98.5%)
(>98.5%)
Confidence
SLIDE 23 Results: Validation Cohort
Risk Validation Cohort with Full Data Set
N=34 High Risk (6/13) 46.2% Low Risk (3/18) 16.7%
High Risk Group is 5x (OR = 5.14; 95%CI: 1.00-26.46) more likely to suffer a 2nd ACL injury than the Low Risk Group Sensitivity = 66.7% Specificity = 72% PPV = 46.15% NPV = 85.71%
SLIDE 24 Summary: Objective Criteria to RTS
Strength/Functional Performance Quality of Movement Patient Reported Outcome
- 1. Strength
- 2. Hop Testing
- 3. Balance
- 1. Biomechanical
Assessment
Assessment Tool
specific tool
SLIDE 25 Thank you!
Mark V. Paterno PT, PhD, MBA, SCS
Coordinator of Orthopaedic and Sports Physical Therapy Scientific Director, Division of Occupational Therapy and Physical Therapy Cincinnati Children’s Hospital Medical Center Professor, Division of Sports Medicine, Department of Pediatrics University of Cincinnati College of Medicine mark.Paterno@cchmc.org @mvpaternopt
