Return to sport specific performance after primary anterior cruciate ligament reconstruction: a systematic review
Mohtadi N and Chan D. Am J Sports Med. [Epub Ahead of Print]. 2017
Take Home Message: Elite level athletes who undergo anterior cruciate ligament (ACL) reconstruction return to sport with little or no decrease in performance.
Anterior cruciate ligament surgery is often performed with the aim of restoring joint biomechanics and allowing an athlete to return to participation with no limitations. Return to pre-injury levels of sports participation varies among groups. A better understanding of how different groups of athletes cope with the injury and subsequent ACL reconstruction would allow clinicians to tailor their education and stratify treatment protocols to provide the greatest benefit to an athlete. Therefore, Mohtadi and Chan completed a systematic review to identify sport-specific performance outcomes after ACL reconstruction. Secondarily, the researchers sought to identify any risk of bias in the published literature. Following a comprehensive literature search according to the PROSPERO International Prospective Register of Systematic Reviews, the authors included 15 articles in the systematic review. All studies were case series or cohort studies that measured sports-specific performance among individuals after an ACL reconstruction. The included studies involved athletes participating in soccer, football, ice hockey, basketball, skiing and snowboarding, and baseball. While not a criterion for inclusion, all athletes competed at an elite level (NCAA division one seeking a professional career, or professional athletes). Following data extraction, the authors evaluated the risk of bias of each study using the Quality in Prognosis Studies (QUIPS) tool. Overall, the authors found high return-to-sports rates ranging from 63% (football) to 97% (ice hockey). Most studies indicated a decline or no change in performance (e.g., less games played, less scoring) following an ACL reconstruction. Only 3 of the 15 studies (football and skiing/snowboarding) reported higher performance after an ACL reconstruction. In studies with a control group, the control group had better performance than the athletes with an ACL reconstruction. The secondary QUIPS analysis identified that all studies had some risk of bias. Twelve studies had a high risk of bias, two had medium risk, and only one had a low risk of bias.
Overall, the results of the systematic review are interesting for all clinicians, but particularly clinicians who treat elite-level athletes. Generally, an elite athlete had little or no declines in performance after ACL reconstruction. Overall, this agrees with other similar studies. However, given this population, there is an additional concern that even a small decrease in performance could negatively impact both an athlete and a team. If an elite athlete experiences a small decline in performance, then it could impact their salary and ability to remain competitive at an elite level. While the authors didn’t look at the potential impact of these declines in performance, it should be considered by clinicians who are helping guide these athletes through an injury and recovery process. Future research could benefit from looking not only at elite level athletes but also at lower level athletes (high school, collegiate). Furthermore, the lack of studies evaluating collegiate and high school athletes presents an opportunity for future research which can be more widely applied to daily practice. Until more studies can be completed, clinicians should add the results of this study to the ever-expanding library of knowledge concerning outcomes after an ACL reconstruction. It is important to discuss results like these (and areas where we just don’t have information) with our athletes so that an athlete can have proper expectations about their post-operative outcomes.
Questions for Discussion: Do the results of this study align with what you have experienced in your clinical practice?