Controversies in Return to Play

Polly de Mille

Theresa A. Chiaia

INTRODUCTION

Scope of Problem

Roughly 2 million anterior cruciate ligament (ACL) injuries occur worldwide each year, 200,000 in the United States. ACL reconstruction (ACLR) is the sixth most common procedure in orthopedics in the United States and the standard of care for athletes who wish to return to their previous level of play.

The rate of primary ACL injury has increased at an alarming rate over the past two decades and shows no signs of diminishing. Lyman et al.¹ showed that ACLRs increased in New York (NY) State by 21.5% and up to 67.8% nationwide over a 9-year period. In a study of NY State hospital admissions, Dodwell et al.² reported a steady increase in the rate of ACLR over the past 20 years in the 3- to 20-year-old age group. ACLR increased from 17.6 per 100,000 in 1990 to 50.9 in 2009, with the greatest rate and greatest increase of ACLR occurring in the 15- to 18-year-old age group.

The rate of ACLR differs between genders particularly in the second decade of life. Young female athletes are at 2.6 times greater overall risk in this age group. A meta-analysis of basketball players indicates that this discrepancy diminishes as maturity and level of play increases. The female-to-male ratio of noncontact ACL injuries decreases at the college level and approaches 1:1 at the professional level.³

More than 38 million children and adolescents participate in sports each year in the United States, and nearly three-quarters of US households with school-age children have at least one child who plays organized sports.⁴ More than 7.8 million high school students, 42% females, participate in organized sports.⁵ Compare that to the roughly 8% of high school athletes who go on to play at the college level.⁶

For a long time, injury to the ACL in the skeletally immature athlete was not a concern. With increased intensity of participation in organized sports, recreational activities and exercise, along with increased recognition, the number of injuries to the ACL in this younger population are increasing. Early on, the focus of the discussion centered on whether this injury should be treated operatively or nonoperatively as adequate protection of the graft in this perpetually active population seemed impossible. The results of nonoperative treatment yielded poor outcomes. Concerns for the immediate trauma to the individual and injury to the knee’s menisci and articular cartilage with recurrent episodes of instability, as well as the long-term health of the knee with the looming consequence of osteoarthritis (OA), have made surgical reconstruction of the ACL the treatment of choice in the individual with a torn ACL. The advent of more skeletal age-appropriate surgical techniques has made reconstruction of the ACL in this population a more attractive option.

The combination of greater numbers of athletes with less refined skills, greater accessibility to play, and physiologic changes associated with growth and development contribute to a unique constellation of risk factors for the pediatric and adolescent athlete who has sustained an ACL injury and wishes to return to play.

Injury to the ACL impacts the life of a child and adolescent in ways different than it impacts an adult. The cost of an ACL injury in the young athlete is not only measured in dollars but also in quality of life issues: social skill acquisition, dependence/independence, identity development, self-esteem, academic performance, and emotional well-being, in addition to the potential loss of scholarship dollars. The injured pediatric individual presents unique concerns related to development, both physical and psychological.

The conundrum of when to return the pediatric athlete to play will be presented. Returning an athlete to sport is the fundamental core of sports medicine.

Consider this: A 12-year-old boy tears his ACL while playing basketball in January. He is an avid lacrosse player in the spring and soccer player in the fall. Following 1 month of prehabilitation, he undergoes an ACLR in February. Immediately, he begins his lengthy postoperative rehabilitation. During this time, this young boy does not go to “gym” class, does not play outside with his friends (free play), does not run around during recess, and does not play in organized sport teams or athletic activities. He is only absent from school for a week, by conservative estimates; however, his grades suffer. During his rehabilitation, he grows 4 in and gains 20 lb. He now must learn to control a new body. The application of the current statistics suggests that this boy may have an arthritic knee by the age of 22 years.¹⁴

RISK OF REINJURY

The pediatric and adolescent athlete who returns to sport following ACLR faces a substantial risk of retear. The estimated rate of rerupture or failure in patients younger than 20 years
of age who return to play following ACLR is 18% to 23%.⁷ In a study of 90 patients 15 years postisolated ACL tear, Hui et al.⁸ reported that patients younger than 18 years of age had a seven times greater odds of contralateral ACL rupture than those older than 18 years of age. The Multicenter ACL Revision Study (MARS) group also found the ACL revision rate highest in young athletes reporting a 22% risk in the 12- to 18-year-old age group.⁹ The significantly elevated risk of injury to the ipsilateral or contralateral knee in young athletes is well-documented and presents a challenge to those involved in return to play decisions for young athletes.⁸,¹⁰,¹¹,¹² Although there does not seem to be a gender difference in the rate of rerupture,¹² the risk of a contralateral tear appears to be greater in females. Paterno et al.¹³ reported that 88% of documented ACL injuries to the contralateral limb occurred in female athletes.

RATE OF RETURN

The ACL is the main stabilizing ligament of the knee. The goal of ACLR is to restore function of the knee, thereby reducing symptoms (pain, instability), improving quality of life (active lifestyle), and minimizing complications (short term [meniscus, articular cartilage] and long-term [degenerative OA] health of the knee) so the individual can return to sport. This is never truer than in the pediatric population, whose existence centers around free play and organized sports and who has many decades of an active lifestyle ahead. For one reason or another, however, these goals have not consistently been met. Even with surgical reconstruction, the risk of developing degenerative knee OA is still a concern.¹⁴

There is considerable data suggesting limited success in returning athletes to their preinjury level of play. A systematic review demonstrated that although 82% of athletes returned to sports, only 63% returned to preinjury level.¹⁵

In a study of 503 competitive athletes, Arden et al.¹⁶ reported that two-thirds had not returned to play at 12 months and less than half were planning on returning despite good functional outcome on International Knee Documentation Committee. The mean age in this cohort was 27.2 years, so it may not be representative of the pediatric and adolescent athlete. Shah et al.¹⁷ reported 63% (31 of 49) National Football League (NFL) athletes with a mean age of 26.2 years returned to NFL game play at an average of 10.8 months following primary ACLR. Sixty-four National Basketball Association (NBA) players (mean age of 25.7 years) with 69 ACL tears were identified with return to sport and performance data between 1975 and 2012.¹⁸ Harris et al.¹⁸ reported that 86% (55 knees) of these players returned to play in the NBA at an average of 11.6 months. Guards had the most difficulty returning to play. Seventy-eight percent of Women’s NBA athletes who tore their ACL returned to play with only a slight decrease in performance.¹⁹ Elite professional soccer players in the Union of European Football Associations (UEFA) following ACLR need 7 months to return to first training, 10 months to return to regular training, and 12 months to return to match play²⁰ (Table 13.1).

In a follow-up study of 314 athletes (mean age 32.7 years), less than half (45%) of these athletes had returned to sport at greater than 3 years after ACLR. However, younger athletes were found to return to preinjury levels of play at a greater rate. Of the 43 athletes younger than 18 years of age, 72% had attempted playing their preinjury sport which was the highest percentage of any of the groups (18 to 25 years, 26 to 32 years, >32 years) but only 49% reported playing at their preinjury level at follow-up.²¹

TABLE 13.1 Return to Play Statistics for Professional Athletes

	Time to RTP (Months)	Athletes who RTP (%)
NFL	10.8	63
NBA	11.6	86
WNBA	11.8	78
UEFA	12	89
RTP, return to play; NFL, National Football League; NBA, National Basketball Association; WNBA, Women’s National Basketball Association; UEFA, Union of European Football Associations.

The Multicenter Orthopaedic Outcomes Network (MOON) group reported 85% of 100 soccer athletes (mean age ♂ 27.7 ♀19.8 years) returned to preinjury level of play.²² Shelbourne et al.²³ provided further evidence that age is inversely related to the likelihood of return to competition. In a study of 413 high school basketball and soccer athletes with mean age of 15.5 years, Shelbourne et al.²³ reported that 87% of the basketball athletes (both boys and girls) returned to high school competition and 93% of the females and 80% of the male soccer athletes returned to competition.

PSYCHOLOGICAL FACTORS

“Other interests” and fear were cited as the primary reasons for failure to return to play rather than physical symptoms in high school and college football players following ACLR.²⁴

Psychological factors may play a significant role in a greater likelihood of return to preinjury level of activity in adolescent athletes following ACLR. In a study comparing adolescent and adult psychological readiness for ACL surgery, Udry et al.²⁵ found that adolescents reported not only higher preoperative mood disturbance levels than adults but also higher levels of “psychological readiness” for surgery. Adolescents reported more pros associated with surgery and used a greater number of cognitive and behavioral processes of change than adults. The greater mood disturbances prior to surgery and the greater “readiness” for surgery may be the result of the central role that physical activity may play in their life at this stage. Adolescents may be more disturbed by the disruption in their usual activities and separation from their peers and more invested in returning to their previous level of activity.

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