The following article is written by Andrew Merritt, MD.
Taking care of injured athletes is one of the most complex and challenging parts of being a surgeon. There is always a conflict between the athlete's desire to return to play as soon as possible, and the surgeon and therapist's desire to err on the side of caution to protect the athlete and recovery from surgery. This conflict is most common with recovery from Anterior Cruciate Reconstruction (ACL) surgery because the rehabilitation timeframe is between 9 and 12 months. This long rehabilitation timeframe causes both the surgeon and the athlete frustration because the recovery often extends into the next season of play. We can see this conflict playing out in real time with the Philadelphia Eagles star quarterback Carson Wentz. His injury occurred last year on December 10th, and the new season starts within the 9-month recovery window from his surgery, causing confusion among the press and coaching staff as to whether or not he will be the starting quarterback this season.
As a sports medicine specialist, I treat many athletes with this exact conflict and frustration. There are a number of factors to consider when evaluating a patient for return to sports, including:
- Injuries to the knee in addition to the ACL (other ligaments, meniscus tear, etc)
- Type of ACL reconstruction
- Th intensity of the sport the athlete plans to return to (soccer and football vs golf)
- Other risk factors for ACL reinjury (high risk in young females, contact athletes, core and hip weakness, previous ACL injury of the same or opposite knee)
- Functional recovery and rehabilitation of the patient
Carson Wentz is a high-risk athlete - returning to professional football - and he injured both the LCL and the ACL, which is a much more severe injury. This makes clearance for his return to play much more difficult. His story was summed up very nicely in an article by ESPN. The physicians and trainers making the decision for his return to play are looking at many more factors than the recovery timeframe. Often, surgeons evaluate time as the only factor for returning to play, but this is actually far from being the most important factor in the decision. Wentz's situation highlights the need for the therapists and surgeon to be on the same page so athletes can properly progress along an agreed timeline, and when the time comes, be fully prepared for sports. Many research studies have highlighted this as the most important factor in preventing reinjury.
Because this is a great need in my sports medicine surgery patients, I have implemented a program to evaluate athletes readiness for return to play. Working with therapists who specialize in this process, we have designed a complete evaluation to measure the injured knee's function and compare it to the other healthy knee. If the player passes this assessment, they can return to their sport knowing that they have the lowest risk of reinjury possible. If the player does not pass, they need more time with rehabilitation, and the evaluation is able to highlight what areas of weakness they need to improve.
Adam Turley at Outpatient Physical Therapy and Caleb Louvier at Valley Medical Center - Lifestyle Medicine, have both been involved in designing and implementing this program from the beginning. Together, they have seen countless athletes recover from ACL surgery and safely return to sports. I discussed with them what specifically they look for in the evaluation process.
Adam Turley works closely in the clinic with athletes, and also works as a teacher and Athletic Trainer at Tahoma High School. We reviewed how he evaluates players as they return to sports, and what he believes are the most important parts of this evaluation.
Two components which play a vital role in the decision for return to play are strength and jump testing. To understand these two components, we must first ask ourselves, what a "good" or "normal" test looks like. It would not make sense to have test standards for a high school student-athlete, compared to those of a professional athlete. For that reason, we determine what is "good" by comparison of the involved knee to the uninvolved for each individual. Research has determined the levels of symmetry which should be demonstrated in the testing to determine a "good" score.
General strength in the lower extremities, hips, and core is also important for an athlete to return to play, but two muscle groups have even greater importance: the quadriceps and the hamstring muscles. Both of these muscle groups function to add dynamic stability to the ACL-reconstructed knee. The side-to-side comparison is determined for both the quadriceps and the hamstrings, and then from that comparison, a quadricep-to-hamstring ratio is established. Both the quad and hamstring index should be at 90% involved to uninvolved before returning to the sport. Hamstring-to-quadricep strength should be at about 67% on the involved leg.
A variety of jump tests are performed to determine lower extremity power and overall confidence in the surgical knee. Some of these tests include the single leg hop for distance, triple hop, side-hop, and single leg vertical jump. These tests are performed with not only a focus on maximum distance but also a strict eye on good "quality" to the jump and landing. This means that optimal mechanics of the lower extremity are maintained through the process of jumping and landing. Research has shown that these tests should be at an 85% level of involvement to uninvolved leg, for a return to practice in the athlete's sport. This increases to a 90% level for a return to competition.
Caleb Louvier at Valley Medical Center - Lifestyle Medicine also works closely with athletes as they transition back to sports. I talked with him about FMS testing which is a tool that is used to evaluate the whole body, not just the leg, and can assess weaknesses and help with full rehabilitation after an ACL surgery.
When evaluating a player who is returning to a sport after ACL surgery, the major focus is on restoring the functional symmetry of the involved knee compared to the uninvolved knee. One tool that is used to evaluate functional symmetry is the Functional Movement Screen (FMS) developed by Functional Movement Systems. It contains 7 movements that expose asymmetries in mobility and stability of the athlete. The FMS primarily assesses the function of the shoulder, hips, and core. The key movements in ACL recovery are the Deep Squat, Inline Lunge, and Hurdle Step which focus on the mobility and stability of the lower extremities. The screen will additionally evaluate the athletes' global core stability, which is also important for full return to sport.
Another strong indicator for safely returning to a sport is symmetry in single leg balance activities in static and dynamic positions. Balance and stability are assessed through the use of specific tests like the Y balance test, single and double leg jump testing and FMS. In physical therapy, balance and stability are the foundation of movement and are therefore assessed throughout the rehab process when spending 1 on 1 time with the athlete. The appropriate retraining of balance and stability are keys in a safe return to sport following ACL surgery.
Together with a good team that includes the surgeon, therapist, and trainer, we can work together to safely return to sports. As you can see, it's not simply a matter of time passed since surgery, it is about functional recovery and rehabilitation. This is the complex decision we see playing out in the media with the case of Carson Wentz, but it also plays out hundreds of times a year in my clinic. Make sure your surgeon has a good team of therapists and follows you through your full recovery because only with a complete, functional recovery can the risk of re-injury be decreased.
Andrew Merritt, MD is an orthopedic surgeon specializing in sports injuries of the knee. He treats athletes of all ages and provides team coverage for many area high schools. For more information about ACL surgery, meniscectomy or knee injuries, please contact Proliance Orthopedic Associates at 425.656.5060 for a consultation.
Adam Turley DPT, SCS, OCS, CSCS
Board Certified Sports and Orthopedic Specialist
Outpatient Physical Therapy & Rehabilitation Services
Covington Clinic 16720 SE 271st St. Covington, WA 98042
Caleb Louvier DPT
Lifestyle Medicine & Fitness Center at Valley Medical Center
4011 Talbot Road South, 1st floor Renton, WA 98058
Read more about the decision facing Carson Wentz and his team at: https://es.pn/2BUr4gk
Read more about injury-prevention warm-up routine at: http://seattlepediatricsportsmedicine.com/injury-prevention/