Where am I supposed to go? It worked. It worked. Okay, good. I have no disclosures. So let me see if I remember what I did. So let me set the stage. ACL injury and reconstruction and reconstruction in athletes, our goal is to return to the previous level of sport without re-injury, knowing that return to sport is the biggest risk for re-injury, right? Exposure. So our overall question is how can we provide the best opportunity for the player to be ready? I see a whole lot of things lie also. So those who – let's talk about first pre-op rehab. What's the evidence for that? Those who receive pre-op rehab that also includes progressive strength and neuromuscular training return to sport at a higher percentage with higher IKDC scores than cohorts and registries that don't. So the evidence is for pre-op beyond a quiet knee, including progressive neuromuscular and strength training, improves outcomes. And the better they are before a surgery, the better they are after. But – and this is what Lyle's talking about – player age, experience, talent, level of play, importance of the competition, and time left in the competitive season play into this decision. So a lot of people are just going to get to the operating room pretty fast. So what about when to start rehab after ACLs? Very early impairment resolution after ACLs with quad strengthening, both open and closed chain, and use effusion and soreness rules to guide program progression. That's where the evidence is. So rehab should begin ASAP. Longer than one week is associated with poorer outcomes. It should consist of active range of motion, aggressive elevation and effusion control, neuromuscular electrical stimulation – I know all this happens in their clinic – open and closed chain quad exercises. So what's the evidence for what criteria we should use to advance? All of these criteria. Knee soreness, effusion, range of motion, losing it is bad, quad strength, functional tests, movement quality, and psychological outcome all have evidence for determining readiness for return to activity. I'm going to just underscore what Lyle said. You pass all those tests, you're ready to start your on-field work, your on-field rehab or on-court rehab. They're not clearance for return to play. Some have stronger associations with safe return, like quad strength and hop tests. They've been around for a long time, but that's what we have the best evidence on. So our criteria to begin running progression, 80% quad index, trace to no effusion, full range of motion equal to the unevolved knee, and no joint pain with ADLs. And I can tell you it takes a long time to get that QI. And our data actually in PREST-2, Lyle shows both hop tests. We have a lot of pre-op data. So the uninvolved leg at six months is equivalent to what it was pre-op. So that's when we start usually return to sport testing, not as early as they do for coach. But in general, if you're doing a good rehab program, at six months, that uninvolved knee is where it was before. So it's a good baseline for hops and quad strength. Formal on-field and on-court rehab, that's really what we're talking about once they pass those tests. Programs like the ones described in this two-part series in JOSPT helps injured players transition safely from the rehab team to practice and match or game play. What about return to activity testing? I think Lyle covered that pretty well. This is the testing that we use for return to activity testing. Same sort of thing. Two PR proms and the single leg hops by noise in Sue Barber-Weston and quad strength over 90%. And that is return to activity, not return to play. I'll just reiterate that. So our study with Dela Rosa Cohort Study, Hager Grendam published that only 6% of patients who passed those criteria before returning to Level 1 sports suffered re-injuries compared to 40% who didn't. In addition to quad strength being part of that, in and of itself, more symmetrical quad strength prior to return significantly reduced the risk of re-injury. Those who returned to Level 1 sports had a five times higher risk of re-injury than those who did not. That is across the board the biggest risk factor for re-injury. But that's why they come in for reconstruction. So there's your conundrum. The risk of re-injury was reduced by 60% for each month return to sport was delayed until nine months after surgery. So we reanalyzed some meta-analysis data and showed that passing return to sport test batteries is associated with a decreased risk of further knee injury by 72%. The odds of any ACL injury by 75% and decreased odds of ACL graft rupture by almost 80%. So what about secondary prevention? I mean, we want no re-injury, right? So the last step in formulating treatment pathways is to develop a way to help prevent the athlete from becoming re-injured. The biggest predictors of risk for injury is previous injury. The athlete and the rehab team must have a plan in place to minimize this risk. So here are a bunch of the same. We do the same. Oops. I went all the way back. Sorry, guys. So we use the same exercises and postures and progressions in secondary prevention than we do in primary prevention. So things like Nordic hamstrings and squats, step-downs, jumping over cones, tuck jumps, right? They look the same. And we use that same progression. And certainly the more advanced of these, we're going to add after they pass agility drills, quad strengthening, continuing, open and closed chain. So our ACL sports trial, which did all of this, we had 75 of 79, they're all young athletes, 39 men and 40 women, pass return to sport by one year, 100% return to play, 87% at their self-reported pre-injury activity level between nine months to two years. So we had 100% exposure for this cohort. We had only one injury of the men at two years and nine in the women. But that's also lower than the literature. One in the men is quite remarkable. Four graphs, five contralateral. So what else? I mean, what else is what Lyle talked about? What additional criteria? Anaerobic threshold, some teams in Europe use that for soccer. GPS. And what about MRI? So the isokinetic medical group has long used anaerobic threshold to match fitness goals to the demands of the match for players returning from injury. And they study, especially the top soccer teams, like they're doing with the GPS, which they're also using now. The use of GPS and related technology has allowed for convenient and accumulative approach to player positional profiling in terms of workload. That is what Lyle just talked about. What were they like before? Its use in professional sports is ubiquitous, also in, you know, high-level collegiate sports. Evidence is mounting for the use of this pre-injury data and position profiles as a benchmark for return to sport. And I look forward to seeing your paper, Lyle. Graft healing and incorporation proceed under the surface. Dr. Constance Chu calls this process silent. And the healing lasts about two years. Patients aren't going to wait for that. Should we begin using the mounting evidence from imaging about this process in our clinical decisions? That's a really big question. I think we'd all be a little scared if we did that, looking at the healing. But it's coming at some point. Should there be strict time restrictions if all criteria are met, and what should they be? So once again here, player age, experience, level of play for sure, talent, importance of the competition, time left in the competitive season, those all play in. I mean, I would say in professional sports, contract issues play into this as well. So what's the evidence? The evidence is no return for nine months and for those under 18 years old, 12 months. But you've got to remember that, what I just talked about. So the key points, return to play after ACL, level one without re-injury, prehab beyond a quiet knee, early rehab, criterion-based progression, pass stringent criteria for running and return to activity, do a secondary neuromuscular and strength training prevention program, pass on-field and on-court progression. And then no return before nine months. Again, I'm talking about the general, most of the people that get ACL reconstruction in this country. And then recommend 12 months for those 18 years and over. In the handouts, I have a lot more slides. Seven minutes isn't a lot of time. So if you want to look at more, they're there. Thank you very much.

ACL injuries

reconstruction

athletes

pre-op rehab

return to play timelines