Posts in ACL Injury
Increased Risk of ACL Re Injury Among NSAID Users

In our previous posts we have detailed the risk factors for ACL injury and the effectiveness of Physical Therapy to reduce this risk especially among adolescents.  A percentage of athletes who return to sport will re injure their ACL leading to further surgeries and Physical Therapy.  A delayed return to sport allows the athlete more time to resolve muscle imbalances and coordination impairments leading to decreased re injury risk.  As we learn more about these athletes who re injure their ACL reconstructions we will have a better idea of how to prevent the injuries.

A recent large study in the The American Journal of Sports Medicine reviewed patient charts who underwent an ACL reconstruction surgery in the US Military over a 7 year period (Pullen et al. 2016).  Over 17,000 procedures were performed over this time period and 587 soldiers underwent revision surgery (3.6%).  The median time to re injury among these individuals was 500 days.  Athletes at greater risk of re injury included younger, active duty soldiers who took anti inflammatory medication during the perioperative period.  This study also identifies the potential harm of taking anti inflammatories during rehabilitation for ACL repair.

Reducing ACL Reinjury Risk

Athletes often return to sports around 6-9 months after ACL reconstruction and Physical Therapy.  In a previous ACL post we described how important these Physical Therapy sessions are to an athlete's recovery.  Each session after surgery is designed to move the athlete closer to the all important return to play.  New research is showing how instrumental this path to recovery is to reduce the risk of ACL re injury.  

Grindem and colleagues studies 106 pivoting sports athletes who underwent ACL reconstruction and Physical Therapy.  The athletes were followed for 2 years to document their rehabilitation, functional performance, and finally return to play.  The authors reported athletes who returned to high level sports had 4 times the risk of re injury compared to lower and mid level sports participation.  Among all athletes, those who did not pass their functional testing before returning were 8 times more likely to re injure their ACL.   Importantly, this re injury rate was cut in half for each month the athlete stayed in rehabilitation and delayed their return to sport up until 9 months.  In short, having athletes who complete 9 months of Physical Therapy and pass their functional tests can reduce their reinjury risk by 84%.

Athletes are advised to work with a local Physical Therapist for 9 months to allow a safe return to competitive sports.  

ACL Reconstruction in Older Athletes

ACL injuries are on the rise across the United States as more individuals participate in athletic activities.  As described in prior posts, the majority of these ligament injuries do not involve contact but rather occur with deceleration and directional changes in sports.   Athletes with decreased strength, balance, and coordination are unable to dissipate forces placing greater loads on their knee ligaments.  One segment of the population at risk of ligamentous injury due to these factors includes “weekend warrior” athletes over the age of 40. 

The necessity of repairing a torn ACL injury in these older athletes is debatable with many patients able to return to activity, albeit often at a lower level, with conservative treatments alone.  A recent review article examined the outcomes associated with ACL repair among athletes >40 years old.  Mall and colleagues analyzed the results of 452 patients (average age 48) who underwent ACL repair (Sports Health. 2016).  The authors reported few complications and a low failure rate among this population along with A or B outcomes in >80% of patients. 

The results of this review suggest ACL repair combined with post operative Physical Therapy is a safe and effective alternative for patients with ACL tears. 


Return to Professional Basketball after Surgery

“In life there are no guarantees” and this is certainly the case with return to sport after surgical procedures.  Unfortunately, the commonly held belief is surgical repairs of muscles, tendons, ligaments, etc. guarantees a return to sport at prior levels of play and competition.  The odds of returning to competitive levels of sport can be improved dramatically through pre and post operative Physical Therapy.   A new review article highlights the lower than expected odds of returning to high level basketball competition after orthopedic surgery.  

We assume professional athletes have a greater likelihood of returning to sports following surgery given their athletic gifts and high levels of resources directed at their care including money, time, and medical staffs.  A recent review article of close to 350 NBA basketball players was conducted to determine the likelihood of these athletes returning to high level play after surgery (Minhas et al. Am J Sp Med. 2016).  The return to sport ranged from 70% in achilles repairs to 98% after hand/wrist surgeries.  Across all procedures older (>30 years old) and heavier (BMI >27) athletes were 3 times less likely to return to sport.  In addition, those undergoing arthroscopic knee surgery or achilles tendon repairs suffered the greatest reduction in performance at both a 1 and 3 year follow up.    Athletes at greatest risk of decreased performance should work closely with a Physical Therapist to facilitate an optimal return to sport.  

Risk of Future Injury after ACL Surgery

In our experience, a sub group of patients who have successfully returned to sports after an ACL injury continue to be at risk for future injury.  Physical Therapy interventions can significantly reduce the risk of future injury to either an athlete's involved or uninvolved leg.  Athletes who complete their prescribed Physical Therapy visits have both the lowest risk and the best chance  to develop the strength, balance, power, and sport specific movements needed to return to the field, court, or ski slopes.  An important area in our Physical Therapy practice and research is to identify these individuals who remain at risk for future injury.     

Prior research reports between 3 and 25% of athletes will re rupture their ACL graft after a return to activity (Dodwell et al. 2014).  New research is helping identify these at risk individuals by following athletes after their return to sports.  A recent review article of 19 studies showed a pooled re injury rate of 15% (7 and 8% for the involved and uninvolved knee, respectively) but this rate reached 23% in athletes under 25 years old (Wiggins et al. American Journal of Sports Medicine, 2016).  The majority of these injuries occurred in the early return to play period highlighting the importance of continued sport specific rehabilitation and Physical Therapy as they return to competitive practice and play.  Overall, an athlete who returns to sport after ACL reconstruction has a 30-40 times greater risk of ACL injury vs. their un injured peers.  

Given 1 in 4 athletes will re injure their ACL after returning to sports Physical Therapists should maintain strict return to play criteria with younger athletes. 

ACL Return to Sport and Physical Therapy Attendance

As ACL injuries continue to rise among professional and recreational athletes Physical Therapists will continue to rehabilitate these athletes in order to allow them to safely return to sports.  In our practice in Boulder, we commonly see athletes over the course of 6-9 months post operatively as they develop the strength, balance, and sport specific movements necessary to return to their prior levels of activity.  Early in the rehabilitation of an ACL surgery attendance at Physical Therapy is extremely important as we reduce inflammation, swelling, pain, and improve ROM.  In the final stages of the program athletes are seen less frequently in clinic, but instead continue to work hard on their home exercise program (HEP) at the gym.  This program is an essential part of any Physical Therapy episode of care and compliance with a HEP has been shown to improve patient's outcomes.   

Recently a study in the American Journal of Sports Medicine highlighted the importance of a patient's compliance with their Physical Therapist's plan of care (Han et al. 2016).  The authors analyzed 93 athletes who underwent ACL reconstruction surgery and then followed them through their Physical Therapy.  The authors were interested in how a patient's compliance with their Physical Therapy sessions impacted their return to sport.  Compliance was assessed as full (attending > 15 sessions), moderate (attending 6-15 sessions), or non compliant (attending <6 sessions).  Patients deemed fully and moderately compliant were 19 and 4 times more likely to return to sport at 1 year, respectively, compared to those in the non compliant group.   

Attendance at Physical Therapy is essential for recovery from many athletic injuries.  These sessions allow the Physical Therapist to deliver appropriate treatments and provide the education a patient will need to self manage their condition.