KNEE & SPORTS MEDICINE
Return to Sport
Return to Sport
Returning to sport is not a single test – nor is it simply a date on the calendar.
After anterior cruciate ligament (ACL) reconstruction and other knee injuries, the goal is not only to restore knee stability. The athlete must regain sufficient muscle strength, movement control, confidence and sport-specific performance while the operated knee and ACL graft continue their biological healing.
In my approach, Return to Sport – a safe return to sport after a knee injury or surgery – is based on objective testing combined with an individual assessment of the athlete, the knee, the sport and the risk of reinjury..
After anterior cruciate ligament (ACL) reconstruction and other knee injuries, the goal is not only to restore knee stability. The athlete must achieve sufficient muscle strength, movement control, confidence, and sport-specific performance while the operated knee and graft continue their biological healing.
'Return to Sport', or a safe return to sports after a knee injury or surgery, is based in my philosophy on objective testing as well as an individual assessment of the athlete, the knee, the sport, and the risk of reinjury.
After anterior cruciate ligament (ACL) reconstruction and other knee injuries, the goal is not only to restore knee stability. The athlete must achieve sufficient muscle strength, movement control, confidence, and sport-specific performance while the operated knee and graft continue their biological healing.
'Return to Sport', or a safe return to sports after a knee injury or surgery, is based in my philosophy on objective testing as well as an individual assessment of the athlete, the knee, the sport, and the risk of reinjury.
Objective testing is the starting point
Objective testing is the starting point
Before returning to sports involving changes of direction, pivoting or other high-risk movements, the athlete should meet clear and measurable Return to Sport criteria.
Testing, however, does not provide a simple pass-or-fail answer. Its purpose is to provide objective information about recovery and identify deficits that might otherwise remain unnoticed.
Before returning to sports involving changes of direction, pivoting or other high-risk movements, the athlete should meet clear and measurable Return to Sport criteria.
Testing, however, does not provide a simple pass-or-fail answer. Its purpose is to provide objective information about recovery and identify deficits that might otherwise remain unnoticed.
Jump tests and other functional tests form part of the Return to Sport assessment.
Jump tests and other functional tests form part of the Return to Sport assessment.
Muscle strength
Muscle strength
Quadriceps and hamstring strength are assessed objectively.
The aim is generally to achieve no more than approximately 5–10% asymmetry between limbs. Symmetry alone, however, is not sufficient. The absolute level of strength must also be appropriate for the demands of the athlete’s sport.
Quadriceps and hamstring strength are assessed objectively.
The aim is generally to achieve no more than approximately 5–10% asymmetry between limbs. Symmetry alone, however, is not sufficient. The absolute level of strength must also be appropriate for the demands of the athlete’s sport.
Functional performance
Functional performance
Jump tests, balance, agility and change-of-direction tests help determine whether improvements in strength translate into functional performance.
Jump tests, balance, agility and change-of-direction tests help determine whether improvements in strength translate into functional performance.
Movement quality
Movement quality
The assessment includes landing control, knee position and control of the pelvis and trunk.
The assessment includes landing control, knee position and control of the pelvis and trunk.
Psychological readiness
Psychological readiness
Confidence in the knee and psychological readiness are important components of returning to sport.
Fear of reinjury and uncertainty may affect both performance and the athlete’s ability to return successfully.
Confidence in the knee and psychological readiness are important components of returning to sport.
Fear of reinjury and uncertainty may affect both performance and the athlete’s ability to return successfully.
Sport-specific load tolerance
Sport-specific load tolerance
Sport-specific load tolerance
Ultimately, the athlete must demonstrate the ability to tolerate progressively increasing sport-specific training loads.
Ultimately, the athlete must demonstrate the ability to tolerate progressively increasing sport-specific training loads.
Testing is only part of the decision
Testing is only part of the decision
Return to Sport is also about risk management.
Two athletes may achieve very similar test results while having very different risks when returning to sport.
In addition to objective testing, I consider three main areas:
- individual and anatomical risk factors
- the demands of the sport
- biological healing.
Return to Sport is also about risk management.
Two athletes may achieve very similar test results while having very different risks when returning to sport.
In addition to objective testing, I consider three main areas:
- individual and anatomical risk factors
- the demands of the sport
- biological healing.
Individual and anatomical risk
Individual and anatomical risk
The risk of reinjury is rarely determined by a single factor. Multiple risk factors may accumulate.
When relevant, the assessment may include rotational knee laxity, meniscal injuries, associated ligament injuries, posterior tibial slope, joint hypermobility and deficits in muscle strength or movement control.
The risk of reinjury is rarely determined by a single factor. Multiple risk factors may accumulate.
When relevant, the assessment may include rotational knee laxity, meniscal injuries, associated ligament injuries, posterior tibial slope, joint hypermobility and deficits in muscle strength or movement control.
Species-specific risk
Species-specific risk
The decision to return to sport must reflect the demands of the sport to which the athlete is returning.
High-speed movements, changes of direction, rotation, contact and high shoe-surface traction all influence ACL injury risk.
Football, handball, basketball, floorball and alpine skiing place very different demands on the knee compared with activities such as running or cycling.
The decision to return to sport must reflect the demands of the sport to which the athlete is returning.
High-speed movements, changes of direction, rotation, contact and high shoe-surface traction all influence ACL injury risk.
Football, handball, basketball, floorball and alpine skiing place very different demands on the knee compared with activities such as running or cycling.
The same test result does not mean the same readiness for every sport.
The same test result does not mean the same readiness for every sport.
Time matters – but time alone is not enough.
Time matters – but time alone is not enough.
Functional recovery and biological healing are not the same thing.
An athlete may feel strong and perform well in functional testing while biological maturation of the ACL graft is still continuing.
Graft remodelling and ligamentisation continue for many months after ACL reconstruction.
Functional recovery and biological healing are not the same thing.
An athlete may feel strong and perform well in functional testing while biological maturation of the ACL graft is still continuing.
Graft remodelling and ligamentisation continue for many months after ACL reconstruction.
A high-risk athlete needs an individual strategy
A high-risk athlete needs an individual strategy
When the risk of reinjury is particularly high, the aim is not only to identify that risk but, where possible, to reduce it.
When the risk of reinjury is particularly high, the aim is not only to identify that risk but, where possible, to reduce it.
Surgery
Surgery
Associated injuries and important anatomical risk factors are considered during surgical planning.
In selected high-risk patients, additional procedures such as lateral extra-articular tenodesis (LET) may be considered.
Associated injuries and important anatomical risk factors are considered during surgical planning.
In selected high-risk patients, additional procedures such as lateral extra-articular tenodesis (LET) may be considered.
Rehabilitation
Rehabilitation
Rehabilitation aims to address deficits in muscle strength, movement control and sport-specific performance rather than simply achieving minimum test thresholds.
Rehabilitation aims to address deficits in muscle strength, movement control and sport-specific performance rather than simply achieving minimum test thresholds.
Timing
Timing
For a high-risk athlete, delaying return to unrestricted pivoting and change-of-direction sport may form an important part of reducing reinjury risk.
For a high-risk athlete, delaying return to unrestricted pivoting and change-of-direction sport may form an important part of reducing reinjury risk.
Selected additional measures
Selected additional measures
In selected cases, MRI may be used to assess graft maturation. In some athletes, temporary use of a functional knee brace may also form part of the overall return-to-sport strategy.
In selected cases, MRI may be used to assess graft maturation. In some athletes, temporary use of a functional knee brace may also form part of the overall return-to-sport strategy.
From rehabilitation back to performance
From rehabilitation back to performance
Returning to sports is a gradual process, not a single moment.
Sport-specific training and a gradual increase in load are an essential part of a safe return to sports.
Sport-specific training and a gradual increase in load are an essential part of a safe return to sports.
Return to running → Return to training → Return to full sport → Return to performance
Return to running → Return to training → Return to full sport → Return to performance
The ultimate goal is not simply to participate again, but to tolerate the physical and psychological demands of training and competition.
The ultimate goal is not simply to participate again, but to tolerate the physical and psychological demands of training and competition.
The goal is not to return as quickly as possible. The goal is to return at the right time – as well prepared as possible for the demands of the athlete’s sport.
The goal is not to return as quickly as possible. The goal is to return at the right time – as well prepared as possible for the demands of the athlete’s sport.
What really matters in Return to Sport?
What really matters in Return to Sport?
Objective testing is the starting point.
The final decision also requires an assessment of individual risk, sport-specific demands and biological healing.
The final decision also requires an assessment of individual risk, sport-specific demands and biological healing.
Reinjury risk is multifactorial and cumulative.
No single test result or risk factor determines readiness to return to sport.
No single test result or risk factor determines readiness to return to sport.
Risk can be modified.
Surgical planning, rehabilitation, appropriate timing and selected additional measures may help reduce overall risk.
Surgical planning, rehabilitation, appropriate timing and selected additional measures may help reduce overall risk.
Return to Sport is always an individual decision.
It is neither a single test result nor simply a date on the calendar.
It is neither a single test result nor simply a date on the calendar.