My name is Lynn Snyder-Mackler, and today, I'm going to talk to you about return to play and tips for minimizing the risk of re-injury after ACL surgery. I have nothing to disclose. Preventing re-injury is another story altogether from primary injury. We all know the dismaying numbers. The overall rate graft rupture plus contralateral ACL rupture is about 30%, and this is absolutely underestimated because all of these numbers assume that 100% exposure, which is 100% of people, go back to sport, and that is absolutely untrue. So for those who return after revision surgery, there's almost an identical risk of a third ACL injury. Unfortunately, our patients do not know these numbers. Ninety-four percent of those undergoing primary ACL reconstruction expect to return to the same level of activity with no or only slight restrictions, and 98% say they have no or only slightly increased risk of developing NEOA. So it's the expectations game to the title of my talk. You don't understand. Sally's the real deal. We're looking at the expectations of the stakeholders. Parents, she's going to get a scholarship to college. The athlete, soccer isn't my main sport. I need to be able to play my senior lacrosse coaches. Sally's the best player on the team. We need her back for the playoff. And other stakeholders, obviously, the healthcare providers and the surgeon, for example, who may say, oh, your knee looks great. You're ready to go back to play, but as the ranks go up, right, the levels of play go up. You have the professional level where you also have management and agents who get in the mix. So what's the biggest risk factor for secondary ACL injury? Number one is returning to level one sports. Younger age is merely a surrogate for return to level one activity. So here's the conundrum. The number one risk for ACL re-injury is return to level one sports. Overwhelmingly, the reason our patients have ACL reconstruction is to return to sports. So first comes education, not just about the dismaying data concerning re-injury, but more importantly, what we can do about it. So this is a very nice infographic used to discuss with your patients. Provided by the NATA, the OA Action Alliance, and the American Academy of Orthopedic Surgeons. This is a really nice graphic about the things that go into shared decision-making over the course of rehabilitation and then the return to activity and return to sports continuum. Tissue health, which we generally measure by physical exam and imaging. Tissue stresses, which are necessary for healing. In this particular paper, they talk about the Goldilocks factor. And they mean it can't be too little, it can't be too much, it has to be just right. And then risk tolerance, which will also change, not only across the continuum of rehab and return to sport, but also based on things like age of the player, level of play, time in a competitive season. So biology matters. This Roadrunner slide is one that I often use to talk about this time period being a race between biologic healing and fixation failure. Graft healing and incorporation proceed under the surface. Dr. Connie Chu calls this process silent, and healing lasts about two years. In current clinical practice, we use time from surgery as a surrogate for graft healing and incorporation. Should we begin to use the mounting evidence from imaging about this process in our clinical decision? We can agree that our patients are not going to wait for two years to return to sport participation. But recent evidence suggests that young athletes will wait for a year. But just waiting to return is not good enough. You need to prepare the need. Secondary prevention starts with impairment resolution on day one after ACL reconstruction. You need a stable base. Full active knee range of motion, good quad contraction with a superior patellar glide, zero to trace effusion, no knee pain, and walking without a limp are our very early goals. Days one to seven, we key in on inflammation control, full active knee extension, patellar mobility. Patellar mobilizations are especially important when the accessory mechanism is used as a graft source. Quadriceps strengthening, open and closed chain, and gait training. We do NMES in our clinic on day one. And we do open and closed chain quad exercises. And here in this paper that we wrote last year on who's afraid of the big bad wolf, you see the science for including open chain exercises and why they are not dangerous. Certainly no more dangerous than walking. Don't cut corners. Throughout rehab, implement prevention exercises in a progressive manner. Promote confidence. You need a strong knee for confidence. Still, instill importance of compliance with rehab and prevention exercise. Use effusion and knee joint soreness to guide progression. Both indicate a poor environment for graft healing. Use strict criteria to begin a running progression. That is time and clinical findings. So no sooner than 12 weeks, an 80% quad index, trace to no effusion, full range of motion equal to the uninvolved knee. No joint pain with ADLs or training activity. And then use a graded running progression to progress to on-field and on-court rehab. We have used this return to activity test battery for more than 30 years. Quad strength index greater than or equal to 90%. All four single leg hop tests as described by Noyce and Farber, greater than or equal to 90%. And these two PROMs greater than or equal to 90%. So passing this return to activity test battery and running progression means they can begin in on-field or on-court return to activity progression and formal knee injury prevention program. Not clearance to return directly to pre-injury level of intensity. Again, from this paper, this consensus paper in BGSM in 2016, they describe this return to sports continuum as first return to participation. Then return to sport. And finally, return to the performance level that they had before injury, which is clearly all of our goals. Compliance is not great with primary prevention programs, despite the overwhelming evidence for knee injury prevention. But motivation should be higher in the secondary prevention scenario because one injury has already occurred. But with secondary prevention, cost visits can be a real barrier. Our secondary prevention program that we used in our ACL sports clinical trial, used or borrowed from the primary knee prevention literature, nor a hamstring curl, standing squat, drop jumps, triple, single leg hops, and tuck jumps, all done in a progressive manner over 10 visits, are also described in our ACL sports protocol paper that was in British Journal of Sports Medicine that also has all of the progression. So, we have them, they start to do full speed agility training. And if they can do that without pain or apprehension, then they go on to unopposed practices for specific skills. If they can do those without pain or apprehension, then and only then do you add an opponent. And then, typically, it's one opponent or best. Adding an opponent is really the danger zone. ACL injuries in sports almost never occurs without an opponent. And then, finally, to full practice with the team. Here are our ACL sports trial outcomes. Seventy-five of the 79 patients passed return to play criteria by one year. And 100% return to play between nine months and two years. This is a graph of our comparisons and our outcomes to the MOON cohort and also to our Delaware-Oslo cohort. So, you can see all of the, actually, all of the ACL sports outcomes are significantly better and clinically meaningfully better in a lot of instances. 13.5 out of 16 for the MARCS activity level, 95.9 for the IKDC at two years, COUS pain, 98, COUS symptoms, 94, COUS ADLs, almost perfect, basically 100%, and COUS sports and rec and COUS quality of life are all also about 10 points higher than the other two. The median age of the men in this sample is 21 and a half years. And all the athletes were regular participants most in great preponderance in level one sports. Two years after ACL reconstruction, all athletes had returned to sport, 95% at their pre-injury level, and only one athlete had a second ACL injury, 23 months after ACLR. And here, I just need to reiterate that exposure matters. 100% of the patients in this study went back to sport. So, our injury rate is an actual injury rate. And in the women, 39 out of 39, 100% returned to sport, 87% at their self-reported pre-injury level. We had four graft ruptures and five contralateral ruptures, both of which are lower than what is, what there exists in the literature. And again, if you look at the fact that we had 100% participation, 100% exposure, these numbers are actual real data about injury, the second injury incident. The quad index at one year and two years, you can see it's around 100%. Same thing with the single leg hopsies are among the best outcomes in the literature. So, as far as implementation is concerned, first, it's education. It's a start as soon as the injury happens. While we know the re-injury data, the expectations of most athletes is a full return to their sports with no or little risk for injury injury. It's necessary to have a talk with the patients, parents, coaches, and other stakeholders. The prevention program is a continuation of the rehabilitation program you've been doing with your patients from day one. It's part of rehab, not standalone. Like primary knee injury prevention programs, the ACL sports secondary prevention program can be done in a group setting in a gym, on a field, and as one good thing to come out of this pandemic, can be delivered and monitored remotely. So, the key points of secondary prevention after ACL reconstruction, rehab begins on day one, resolve impairments, start by building a strong base. Past stringent criteria for running and return to activity, incorporate secondary injury prevention exercises progressively throughout rehab, and then progress to a formal program in an individual group or remote delivery format. And pass on field and on court progressions using soreness rules and effusion testing. Respect biology, no return before nine months. And if the patients are under 18, we recommend not returning before a year. Thank you very much. And here's my Sally, my granddaughter Sadie.

ACL surgery

re-injury prevention

graft rupture

contralateral ACL rupture

return to level one sports