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Team Approach: Return to Play After Anterior Cruciate Ligament Reconstruction

Dean Wang, MD Abstract » Current surgical and rehabilitation techniques have allowed for a Theresa Chiaia, PT, DPT relatively high rate of return to sports after anterior cruciate ligament John T. Cavanaugh, PT, MEd, (ACL) reconstruction. Although some patients may be expected to ATC, SCS return to sporting activities by as early as 8 months after the surgical procedure, most patients will have not achieved the appropriate Scott A. Rodeo, MD rehabilitation benchmarks by this time point and can require as long as 2 years to reach their full preoperative level.

Investigation performed at the Sports » In addition to the diagnosis and surgical treatment of the ACL injury, Medicine and Shoulder Service and the the surgeon has to educate the patient about the injury, treatment, Sports Rehabilitation and Performance and rehabilitation process. Center, Hospital for Special Surgery, New York, NY » The physical therapist commonly spends the most time with the patient and therefore must foster a relationship of trust early on with the patient-athlete. Through biomechanical evaluations, factors that contributed to the ACL injury and ongoing deficits during the rehabil- itation process are identified and are addressed.

» Assessment of movement quality complements the traditional quan- titative measures of performance and informs the medical and rehabil- itation team, as well as the patient, of the presence of potentially faulty movement patterns associated with an ACL injury.

» Throughout the course of rehabilitation, the certified athletic trainer works closely with the physical therapist to ensure athlete compliance with the prescribed exercises. Communication between the physical therapist and the certified athletic trainer therefore plays an integral role in the patient’s rehabilitation. During the return-to-play phase of rehabilitation, the certified athletic trainer serves as the liaison between the patient, surgeon, physical therapist, and coaching staff.

» This team approach to managing the athlete’s injury, rehabilitation, and expectations is key to a successful outcome.

nterior cruciate ligament sports involving cutting, pivoting, and (ACL) reconstruction is com- jumping maneuvers. Recent advancements monly performed in athletes in surgical techniques and rehabilitation who sustain an ACL injury have contributed to a relatively high rate of withA the goal of returning them to preinjury return to play after ACL reconstruction1. levels of sports participation, particularly in Although some patients may be expected to

Disclosure: Disclosure of Potential COPYRIGHT © 2019 BY THE There was no source of external funding for this study. The JOURNAL OF BONE AND JOINT Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ SURGERY, INCORPORATED JBJSREV/A405).

JBJS REVIEWS 2019;7(1):e1 · http://dx.doi.org/10.2106/JBJS.RVW.18.00003 1 | Team Approach: Return to Play After Anterior Cruciate Ligament Reconstruction

return to sporting activities by as early as to 5 mm, grade 2 5 6 to 10 mm, and 8 to 9 months after the surgical proce- grade 3 5.10 mm increased transla- dure, most patients will not have tion compared with the uninjured side). achieved the appropriate rehabilitation The pivot-shift test was 21 in the left benchmarks by this time point and can knee and 0 in the right knee (0 5 nor- require as long as 2 years to return to mal, 115glide, 215clunk, and play2,3. Return-to-sport recommenda- 315gross). There was lateral joint line tions following ACL reconstruction are tenderness. Magnetic resonance imag- varied but are typically based on ing (MRI) demonstrated a proximal Fig. 2 assessments of knee impairment and ACL rupture with the characteristic Photograph showing low-load prolonged function, such as knee range of motion, bone edema pattern on the posterolat- stretching to facilitate extension of the left quadriceps strength,andfunctionaltest eral tibial plateau and middle of the lat- knee. performance. The clinical scenario eral femoral condyle. Additionally, there presented in this review is an example of was a peripheral tear in the posterior crutches were discontinued 5 weeks after the team approach that is required horn of the lateral meniscus without the surgical procedure upon demon- between the surgeon, athletic trainer, displacement. stration of a non-antalgic gait without and physical therapist for treating ath- Prior to the surgical procedure, deviations and control of pain and letes after ACL injury to optimize their rehabilitation was initiated to maximize swelling. She progressed well through- chances of returning safely to sport at a range of motion and function. Follow- out the ensuing course of rehabilitation, high level. ing 3 weeks of physical therapy, the achieving full symmetrical range of patient’s range of motion and gait had motion by 10 weeks postoperatively. At Clinical Scenario normalized, and she demonstrated the approximately 3 to 4 months, quality of A 16-year-old female high school soccer ability to actively contract the quadri- movement became the focus during player sustained a non-contact left knee ceps. The patient then underwent an body-weight exercises. The patient injury during a game while attempting ACL reconstruction with bone-patellar demonstrated a pain-free, 8-inch (20- to kick the ball out of bounds on defense. tendon-bone autograft and all-inside cm) forward step-down without devia- She recalled her knee buckling when she lateral meniscal repair. Postoperatively, a tions, and, thus, progressive plyometric planted her left leg. There was no history commercial cold and compression training and running programs were of knee injury. She presented to the device (Fig. 1) was prescribed for home initiated. Controlled soccer-specific office 6 days after the injury and reported use to control postoperative inflamma- agility programs were introduced. mild pain and residual swelling in the tion and pain. Her weight-bearing was At 6 months, the patient under- knee. The physical examination dem- protected for the first week and was then went a quality-of-movement assess- onstrated normal alignment; however, transitioned to weight-bearing as toler- ment. Her first quality-of-movement she was walking with a bent knee gait. ated with her postoperative brace locked assessment revealed that she had a very The left knee had a 21 effusion. The at 0° of extension. The patient was in- good movement strategy on 2 legs as she range of motion was 5° to 120° of flexion structed by a physical therapist to begin a initiated and continued to drive move- in the left knee and 22° to 135° of home exercise program consisting of ment with the hips. However, she was flexion in the right knee. The Lachman low-load prolonged stretching to pro- asymmetrical, shifting to her right (non- test was 2B in the left knee (A 5 firm end mote full passive extension (Fig. 2); injured) side with take-off and landing point and B 5 no end point; grade 1 5 3 quadriceps setting in a supine or seated during the double-leg squat and jump in position, active-assisted range-of- place. Additionally, during the single-leg motion (knee flexion and extension) squat, she initiated movement with the exercise; and active range-of-motion knees, and the left knee collapsed into ankle exercises. Formal physical therapy valgus because of insufficient use of the was initiated 1 week after the surgical posterior chain (gluteals and ham- procedure and focused on restoring strings) (Fig. 3). This strategy placed range of motion and gait, patellar increased strain on her graft. Therefore, mobilization, and minimizing knee it was recommended that she work on effusion. At 3 weeks, the patient dem- single-leg gluteal and eccentric quadri- onstrated full passive extension range of ceps strength as well as single-leg motion and good quadriceps control. movement strategy. The broad jump Fig. 1 The postoperative brace was then and forward hop from 1 leg to the Photograph showing Game Ready, a com- mercial cold and compression device used to opened to 60° to assist in restoring a opposite leg (hop to opposite side) as- control postoperative inflammation and pain. normal gait pattern. The brace and sessed her ability to control shear forces.

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Fig. 3 Photographs showing a single-leg squat on the left knee at 6 and 10 months after ACL reconstruction. Left: At 6 months, the patient demonstrated poor alignment and balance. Right: At 10 months, the patient demonstrated improved movement strategy, alignment, and balance, with loading of the knee in a safer position.

At 8 months, the patient returned she was upright and lacked control turn to full play at that time. She con- for the second quality-of-movement during single-leg landings and cutting, tinued to work with her certified athletic assessment and she was anxious to return with valgus noted. Gluteal and quadri- trainer on single-leg strengthening, to soccer. In addition to her weekly ceps weakness persisted, which contrib- agility with resistance, and deceleration physical therapy sessions, she had been uted to her lack of ability to decelerate. training, and on her own for isolated working on sprinting, agility, and speed She continued to move through the strengthening of the quadriceps, glu- with her athletic trainer twice weekly. knees on 1 leg (Fig. 4). Because of these teals, and hamstrings. At 10 months, During landings from horizontal jumps, deficiencies, she was not cleared to re- she returned for the third quality-of-

Fig. 4 Photographs showing a cutting movement on the left knee at 8 and 10 months after ACL reconstruction. Left and middle: At 8 months, the patient demonstrated poor alignment with the cutting movement on the left, surgically treated knee compared with good alignment (and safe loading) on the right, uninvolved knee. Right: At 10 months, the patient demonstrated improved alignment with the cutting movement on the left, surgically treated knee.

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movement assessment. At that time, she have highlighted the importance of of a concomitant meniscal repair, knee displayed a hip strategy during single-leg psychological factors and fear of reinjury flexion should be limited to 90° in the squats (Fig. 3), good control and align- on outcomes and rate of return to play early postoperative period to avoid ment during an 8-inch (20-cm) forward after an ACL injury. Higher preopera- excessive loads on the repair site prior to step-down, and a 30-second hold on a tive Short Form (SF)-12 mental com- its full healing. Nevertheless, several single-leg bridge. This translated to ponent summary scores have been goals remain constant for rehabilitation symmetry during double-leg tasks and shown to be predictive of achieving after ACL reconstruction, which include control on the affected leg with good clinically important improvements after restoring motion and quadriceps alignment during dynamic single-leg ACL reconstruction4,5. This emphasizes strength and progression of functional tasks (Fig. 4). The isokinetic test re- the importance of setting realistic activities that do not exceed the limits vealed a 95% limb symmetry, and the expectations preoperatively with of graft healing. Early emphasis on re- functional hop tests revealed a 97% patients and considering any psycho- establishing full extension is important limb symmetry. On the basis of her logical, social, or emotional factors in for quadriceps function. Because of the performance on the latest quality-of- the decision-making process. associated problems with stiffness after movement assessment, she was allowed The timing of the surgical proce- ACL reconstruction, more aggressive to progressively return to playing soccer dure is critical, as ACL reconstruction protocols that allow for early range without a brace. performed in the early period after injury of motion and immediate weight- increases the risk of postoperative bearing have become more widely Team Approach arthrofibrosis5-8. Postoperative loss of adopted9,11,12. These protocols need to Orthopaedic Surgeon motion, particularly loss of terminal be balanced against evidence suggesting The orthopaedic surgeon is typically one extension, is correlated with decreased that a brief period of immobilization of the first members of the team to patient satisfaction, functional limita- and protected weight-bearing may be evaluate the patient after the initial tions in sport activities, and the devel- beneficial for graft healing at the injury. Thus, the surgeon has the opment of osteoarthritis in the long tendon-bone interface13. Although important responsibility of educating term9. Patients undergoing a surgical inadequate healing may be only one of the patient about the injury, describing procedure with knee extension loss are several factors that contribute to graft the treatment options, providing an 5 times more likely to have extension failure, rehabilitation in the immediate overview of the rehabilitation process, loss issues after a surgical procedure8. postoperative period clearly has an and setting realistic expectations about Patients who have an effusion and stiff- important role in graft healing and graft return to play. Making the diagnosis is ness beyond 4 weeks after the injury who incorporation, and further research is really just a small part of the initial undergo ACL reconstruction are also at needed to understand the optimal patient interaction; rather, the surgeon high risk of developing arthrofibrosis, amount of motion and mechanical has to educate the patient about the suggesting that a surgical procedure loading that is needed to reduce the risk injury, treatment, and rehabilitation performed on an actively inflamed knee of ACL graft failure. One of the guiding process. The surgeon is also responsible plays an important role in the develop- principles of return to play is that the for organizing and overseeing the team ment of postoperative stiffness. Because timeline should not outpace the phys- that will participate in all phases of the preoperative range of motion is predic- iology of the surgical reconstruction. patient’s treatment. Patients come in tive of postoperative range of motion Return to play should be a coor- with varying levels of knowledge, fears, and can be improved with preoperative dinated decision between the patient, and questions about the injury, and the rehabilitation, the ideal approach is to surgeon, physical therapist, and athletic surgeon’s job is to address these issues. allow for swelling to resolve and for the trainer. Fitness is often well perceived by The nuances of graft selection, the patient to regain full range of motion the physical therapists and athletic impact of other concomitant pathology prior to the surgical procedure10. trainers but tends to be overlooked by on the treatment and outcome (meniscal Many factors should be considered orthopaedic surgeons because it is not or chondral injury, for example), and the with regard to the progression of reha- typically gauged by the surgeon in the long-term risk of posttraumatic arthritis bilitation after ACL reconstruction. office. Therefore, the objective data need to be addressed. These factors include graft type, place- provided by quantitative and qualitative Setting appropriate and realistic ment of the graft relative to the anatomic assessments can inform orthopaedic expectations is critical. The impact of location of the native ACL, graft fixa- surgeons regarding any existing neuro- patient expectations on postoperative tion, the presence of associated injuries muscular deficits in the patient, which patient satisfaction has received in- (e.g., meniscal tear, multiple ligament helps with counseling the patient and creased attention across orthopaedics, injury), and individual patient-specific reinforces the message that the patient especially for common procedures such factors (e.g., knee laxity, tibial slope, age, may be receiving from all other parties as ACL reconstruction. Recent studies activity level). Forinstance, in the setting on his or her readiness for return to play.

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Additionally, mental fitness remains a core, gluteal, and hip strengthening ence of potentially faulty movement key component of return to play that creates a platform for effective quadri- patterns that have been associated with may require special attention from a ceps function. This allows the patient to ACL injury and the factors that may sports psychologist or similar specialist. progress to body-weight exercises and contribute to these faulty movements. Orthopaedic surgeons should be able to single-leg function. As rehabilitation These factors can be related to strength, make these types of referrals if they progresses to 12 weeks, the focus of in which the athlete does not have believe that it can be beneficial for the rehabilitation shifts to the whole patient, enough strength to support the move- patient. in addition to ongoing rehabilitation of ment; range of motion and/or flexibility the involved extremity. Faulty move- deficits that limit the athlete’s ability to Physical Therapist ment patterns are strongly implicated in perform the movement; and/or move- The physical therapist meets the patient ACL injury and have been described as a ment know-how, such as in athletes who early on in the rehabilitation process. As combined loading pattern of decreased do not know how to engage the hips. A the person who spends the most time hip and knee flexion, femoral internal knee-dominant strategy will increase with the patient, the physical therapist rotation, knee valgus, and high quadri- ACL graft strain and patellofemoral must foster a relationship of trust early ceps activity not balanced by the ham- stress19. Targeted recommendations on with the patient-athlete as they strings16. Because ACL injuries are address any identified deficits to correct embark on this journey of return to play typically non-contact injuries, it is these movement patterns and ultimately together. The physical therapist gains imperative to identify and address the allow the athlete to safely return to play. an understanding of the patient, the risk factors that may have led to the patient’s goals, the patient’s personality, injury. Are there deficits that lead to this Certified Athletic Trainer and how to get the most from the faulty movement pattern? A biome- In the clinical scenario, a certified ath- patient. Expectations are continually chanical evaluation helps to identify letic trainer was a member of the reinforced. The physical therapist ad- factors that contribute to the risk of patient’s medical team and was able dresses thedeficits createdby the surgical the knee collapsing into valgus during to work with her at her high school. procedure and the injury. Through a single-leg squat. Deficits in ankle Throughout the course of rehabilita- biomechanical evaluations, factors that mobility and gluteal strength, which tion, the certified athletic trainer works contributed to this injury are identified contribute to faulty movement patterns, closely with the physical therapist to and are addressed. Education is the are also identified and are addressed. The ensure athlete compliance with the mainstay of the rehabilitation process as use of videos of the patient performing prescribed exercises, making sure that it not only increases compliance with specific movements is paramount to they are done correctly with the correct the rehabilitation process, but also changing these movement patterns as it intensity, volume, and movement. The empowers the athlete to take ownership allows the patient to directly appreciate certified athletic trainer also acts as of his or her recovery of function. The the factors that may have contributed to another individual to monitor the var- physical therapist takes on the role of the injury. These videos also inform the ious elements of activity modification captain of the rehabilitation program by orthopaedic surgeon and allow physical recommended by the surgeon and facilitating communication between all therapists to track progress. physical therapist. Communication parties. Accordingly, ACL injury preven- between the physical therapist and The focus during this immediate tion programs have been developed the certified athletic trainer therefore postoperative phase is control of pain to decrease the risk of ACL injury plays an integral role in the patient’s and swelling to promote active quadri- by correcting these faulty movement rehabilitation. ceps contraction and range of motion. patterns17,18. For instance, the Hospital The role of the certified athletic Poor compliance with postoperative for Special Surgery quality-of-movement trainer takes on considerably more activity modification and weight- assessment consists of a series of pur- responsibility if or when a patient is bearing will result in increased pain and posefully selected tasks that progress in a limited in the number of physical ther- swelling with subsequent loss of range hierarchal fashion from relatively static apy visits allowed by his or her insurance of motion and inhibition of quadriceps to dynamic tasks, from 2 legs to 1 leg, carrier. During the return-to-play phase function14,15. During the first 6 weeks and from vertical to horizontal landings. of rehabilitation, the certified athletic of rehabilitation, the physical therapist The assessment of movement quality trainer serves as the liaison between the should aim to protect the graft and complements the information gathered patient, surgeon, physical therapist, and donor site and needs to consider the from traditional quantitative measures coaching staff. The certified athletic functional deficits created by the initial of performance. Data gathered from trainer, who is typically directly present trauma of injury and the second trauma the quality-of-movement assessment on the field, can directly supervise the of the surgical procedure. As rehabilita- inform the medical and rehabilitation amount of athletic exposures. The vol- tion progresses, a solid foundation of team, as well as the patient, of the pres- ume of activity needs to be carefully

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monitored during daily and weekly ORCID iD for D. Wang: J Sports Med. 2011 Dec;39(12):2536-48. Epub 2011 Sep 27. practice sessions so as to deter fatigue 0000-0002-3005-1154 10. Wilk KE, Arrigo CA. Rehabilitation principles and thus decrease the chance of reinjury. ORCID iD for T. Chiaia: 0000-0003-0334-9438 of the anterior cruciate ligament reconstructed knee: twelve steps for successful progression ORCID iD for J.T. Cavanaugh: Conclusions and return to play. Clin Sports Med. 2017 Jan; 0000-0002-7045-8661 36(1):189-232. The importance of both precise surgical ORCID iD for S.A. Rodeo: 11. Beynnon BD, Uh BS, Johnson RJ, Abate management and careful and compre- 0000-0002-0745-9880 JA, Nichols CE, Fleming BC, Poole AR, Roos H. Rehabilitation after anterior cruciate hensive rehabilitation points out the ligament reconstruction: a prospective, References critical importance of a team approach, randomized, double-blind comparison of programs administered over 2 different 1. 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