ACL Return to Play Toolkit

Pediatric Anterior Cruciate Ligament (ACL) Return to Play (RTP) Toolkit

One out of every four young athletes returning to sports following treatment for an ACL injury will have a secondary ACL injury. Although graft healing is historically based on time estimates, a young athlete must also demonstrate functional healing (i.e. “readiness”) prior to returning to play.

Returning patients to pre-injury sport/activity is an important goal of treatment after pediatric ACL reconstruction.  Patients often “feel” ready to play sooner than objective, functional, or psychological findings may suggest.  This “toolkit” is meant to provide guidelines, resources, and a structure for returning young athletes to play.

An emphasis should be made to discuss a RTP strategy with patients and families both BEFORE surgery and when discussing readiness to return to sport/activity following ACL surgery or injury.

Return to Play Toolkit: 

 Pre-operative discussion about:

• Importance of adherence to post-operative restrictions
• Importance of adherence to post-operative rehab protocol
• Align patient, family, and coach expectations
• Pediatric patients are vulnerable population at INCREASED risk of re-injury after ACL-R particularly with early (<1 year) return to sport**

 Time from surgery >9 months

• Rationale: Risk of early re-rupture (<1-year post-op) is high in young patients
  • Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury.
  • Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL Reconstruction: Prospective Analysis of 2488 Primary ACL Reconstructions From the MOON Cohort.
  • Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study.
• Allow graft maturation and full neuromuscular recovery prior to increasing physiologic loads
• Acknowledge that there is poor correlation and variability between time from surgery to readiness for return to sport
  • No association of time from surgery with functional deficits in athletes after anterior cruciate ligament reconstruction: evidence for objective return-to-sport criteria.
  • Young Athletes After Anterior Cruciate Ligament Reconstruction With Single-Leg Landing Asymmetries at the Time of Return to Sport Demonstrate Decreased Knee Function 2 Years Later.
  • Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. 

 Physical exam

• Gait/Run
  • Qualitative evaluation
    • No limp or gait asymmetry
• Affected Knee Exam
  • No pain, no effusion, functional AROM/PROM restored
  • Stable Lachman test, negative anterior drawer test, negative pivot shift test
• Assessment of ankle dorsiflexion
  • Decreased ankle dorsiflexion associated with knee injuries
    • Altered knee and ankle kinematics during squatting in those with limited weight-bearing-lunge ankle-dorsiflexion range of motion.
    • Ankle-dorsiflexion range of motion and landing biomechanics.
  • Decreased ankle dorsiflexion associated with increased dynamic knee valgus
    • The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and meta-analysis.
• Strength Assessment
  • Manual muscle testing symmetric to contralateral side
    • Knee extension/flexion
    • Hip abduction/extension/external rotation

 Patient reported outcome measures

• http://www.prismsports.org/research/patient-reported-outcome-measures/knee

Functional measure milestones (assessed and documented by licensed physical therapist): 

• Balance
  • Single-leg hop testing (≥90% contralateral side)
    • Single-leg hop for distance
    • Single-leg hop timed (6-meters)
    • Triple hop for distance
    • Triple crossover hop for distance
    • Assessment of movement quality in addition to Limb Symmetry Index
    • https://youtu.be/5AHfRwwpwa0
• Lower Extremity Y-balance testing (≥90% contralateral side)
  • https://www.scienceforsport.com/y-balance-test/
• Observational, qualitative drop jump testing (i.e. LESS [Landing Error Scoring System])
  • https://www.scienceforsport.com/landing-error-scoring-system-less/
  • The Landing Error Scoring System as a Screening Tool for an Anterior Cruciate Ligament Injury–Prevention Program in Elite-Youth Soccer Athletes.
• Agility
  • Vail Sports Test - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3290923/#app1

 Referral to ACL injury prevention program

• FIFA 11+
• Sportsmetrics^TM 
• PEP Program

 Appropriate Use Guidelines for ACL Prevention Program

Discussion of psychological factors related to return to sport

• Consider:
• ACL-RSI Short form
• Tampa Scale of Kinesiophobia
• Athletic Skills Coping Inventory
• Note: Above scales not yet validated in pediatric population 

 Discussion of re-injury risk in pediatric/adolescent patients

• Return to Sport After Pediatric Anterior Cruciate Ligament Reconstruction and Its Effect on Subsequent Anterior Cruciate Ligament Injury.
• Over 90 % of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

Discussion of efficacy of ACL functional bracing

• Functional Bracing After Anterior Cruciate Ligament Reconstruction: A Systematic Review.