Evidence-Based Physical Therapy (EBP) uses the best research evidence with clinical expertise and user’s preferences to produce the most appropriate and effective care. At week 43 in 2023, we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of Applied Science about EBP. This BIP program opened with welcome words of the president of The European Network of Physiotherapy in Higher Education (ENPHE) and followed with the basis of EBP and teachers who highlighted the main challenges at different Physical Therapy fields week 43 in 2023 we had Blended Intensive program (BIP) in Finland, Kuopio Savonia University of applied science. More than 40 physiotherapy students and 7 teachers from three universities (Savonia University of Applied Sciences, Finland, Universidade da Coruña, Spain, and Charles University Prague, actively participated this week and shared experiential group dynamics and social activities. Students worked together and wrote articles devoted to the following themes: Evidence Based in McKenzie, back pain, spinal cord injuries, aquatic therapy, ergonomics at work, Nordic walking, sport injuries, sport and young adults: Prevention of sport injuries and children with disabilities. In the following you can consult the works presented by the students on each topic.

ACL Reinjury in Athletes

In the competitive of sports, athletes confront numerous challenges, one of the most daunting being the risk of Anterior Cruciate Ligament (ACL) injuries. These injuries can be life-altering, requiring painful surgeries, extensive rehabilitation, and the unsettling potential for reinjury. (McPherson et al. 2019) Athletes must grasp the factors contributing to this risk and embrace strategies to mitigate it. In this blog post, we delve into the latest research and offer valuable insights, complete with percentages, to help athletes minimize the risk of ACL reinjury and confidently return to the field.

Statistically, ACL reinjuries are an unfortunate reality for many athletes. Recent study by Wong et al. (2023) revealed that approximately 25% of athletes who return to sports after ACL reconstruction (ACLR) experience a second ACL injury. This statistic emphasizes the urgency of understanding the factors influencing this risk.

A study by Zarzycki and colleagues (2023) has shed light on an unexpected trend. Athletes with better psychological readiness are at a higher risk for a second ACL injury following primary ACL reconstruction. Surprisingly, psychological factors, such as kinesiophobia (fear of movement), knee confidence, and psychological readiness, have been linked to second ACL injuries. In fact, studies show that 70% of athletes who experienced a second ACL injury had a more positive psychological outlook. These findings underscore the importance of psychological assessment and counseling in reducing reinjury rates.

A study by Cronström et al. (2023) pointed out that “time” plays a pivotal role in preventing ACL reinjury. The study on ACL reconstruction patients found that returning to high-intensity sports too early can significantly increase the risk of ACL reinjury. Specifically, athletes who returned before nine months had a higher reinjury rate. In fact, the risk was reduced when athletes passed return to sport (RTS) criteria, that are different for every sport (Davies et al. 2017).

Webster and Feller (2019) have shown us that a substantial percentage of patients expect to return to sport at their preinjury level (63%) before undergoing their revision surgery. However, after 12 months, only 12% of patients actually achieved this expectation, while 14% have already given up on returning to sports. Notably, the fear of reinjury is cited as the main reason for athletes giving up on their sports career, accounting for 71% of cases. In one study, Grindem et al. (2016) restoring muscle function before RTS is regarded as another important factor in lowering the re-injury risk. It is commonly regarded that a limb symmetry index (LSI) of over 90% for both leg muscle strength and hop performance after ACL injury and reconstruction is sufficient to reduce the reinjury risk.

When trying to reach a greater quadriceps limb symmetry index, open kinetic chain exercises such as knee extensions are often used. And although some health experts may be afraid of implementing such exercises in their rehab protocols, the Aspetar guidelines (Kotsifaki et al., 2023) say it is completely safe for patients to start open chain exercises in limited range (90°−45° of knee flexion) of motion from the fourth week after surgery. The reason for this limited range is that we want to engage in strength training as soon as possible but at the same time we do not want to compromise the graft. As it has been shown by Escamilla (2012) the ACL ligament is under zero load at 60 and 90 degreesy, therefore both isometric and isotonic strengthening in these ranges is safe. The peak ACL strain is between 15 and 30 degrees of flexion, therefore it is advised to avoid this range at the beginning of rehab, also this is the range where all of the injuries occur.

According to Beischer et al. (2018) two identified risk factors for an additional ACL reconstruction are primary ACL reconstruction at a younger age, i.e., age < 20 years, and a higher activity level. Especially adolescent patients (15–20 years) run a remarkably increased risk of a second ACL injury; up to 30% will require a new ACL reconstruction within the first two years after RTS. The majority of young athletes make an early return to knee-strenuous sports after a primary ACL reconstruction, without recovering their muscle function. To set realistic expectations, it is recommended that clinicians ensure young athletes receive information about not returning before muscle function is recovered, and that this may take longer than 12 months.

The review of literature done by Rambaud AJM, et al (2018) proposes that there is no universal timeline for safe return to running, the time needed is going to differ between patient to patient, therefore when deciding whether the patient is ready to start running safely or not our clinical decision making should be based on combination of performance, clinical and time-based criteria. The main performance based criteria for safe return to running proposed by Aspetar guidelines (Kotsifaki et al., 2023) are 95% knee flexion ROM, full extension ROM, no effusion/trace of effusion, limb symmetry index (LSI)>80% for quadriceps strength, LSI>80% eccentric impulse during countermovement jump, pain-free aqua jogging/Alter-G running, pain-free repeated single-leg hopping (‘pogos’). Of notice is that time is not mentioned in these criteria and even in the criteria for return to sport.

In conclusion reducing ACL reinjury is paramount for athletes looking to overcome the obstacles and setbacks of ACL injuries. Statistics reveal the significant risk of reinjury, and psychological and physical factors have emerged as contributors. Du et al. (2022) found that managing patient expectations, focusing on muscle strengthening, and adhering to an appropriate RTS timeline are vital components of the solution.

Based on the studies with the right strategies and knowledge, athletes can decrease the risk of ACL reinjury and pursue their passion for sports with confidence. And in our opinion collaborative efforts between athletes and healthcare professionals can ensure a safe and successful return to sports, while being aware of the statistics and the factors influencing reinjury rates is the first step toward achieving this goal.

Learning experience:

We learned the importance of setting realistic expectations for athletes during their recovery. The statistics showing that many athletes expect to return to their preinjury level, but only a fraction actually achieve this, showcased the need for transparent communication with patients. We realized the significance of educating athletes about potential challenges and the time required for muscle function recovery.

The experience underscored the importance of timing and muscle strength in ACL injury prevention. Delaying the return to sports and ensuring that athletes achieve a specific limb symmetry index (LSI) for muscle strength and hop performance emerged as concrete strategies to reduce the risk of reinjury. We discovered the importance of evidence-based practices in sports medicine.

Authors:

Kalander, Juho, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Karvonen, Oona, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

López García,   Jorge, Physiotherapy student, University of Coruña (UDC), A Coruña, Spain

Ráž, Jiří, Physiotherapy student, Faculty of Physical Education and Sport at Charles University, Prague, Czech Republic

Stuchlíková, Kateřina, Physiotherapy student Faculty of Physical Education and Sport at Charles University, Prague, Czech Republic

Timonen, Jussi, Physiotherapy student, Savonia University of Applied Sciences, Kuopio, Finland

Marja Äijö, PhD, PhD, Principal lecturer of gerontology and rehabilitation, Savonia University of Applied Sciences, Finland

Mari Tuppurainen, physiotherapy lecture, Savonia University of Applied Sciences, Kuopio, Finland

Dagmar Pavlu, Physiotherapist, Assoc. Prof. Charles University, Czech Republic

Ivana Vláčilová, Professor, Charles University, Czech Republic

Jamile Vivas Costa, PhD, MSc, PT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at Psychosocial intervention and functional rehabilitation group,  Universidade da Coruña, Spain

Montserrat Fernández Pereira, MSc, PT.  Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Physiotherapist at Spinal Cord Injury Unit, A Coruña Hospital (CHUAC), Spain

Verónica Robles García, PhD, MSc, PT, OT. Lecturer at Department of Physical Therapy, Medicine and Biomedical Sciences, Faculty of Physiotherapy and Researcher at the Neuroscience and motor control group,  Universidade da Coruña and Biomedical Institute of A Coruña, Spain

References:

Beischer, Susanna, Senorski, Eric Hamrin, Thomeé, Christoffer, Samuelsson, Kristian & Thomeé, Roland 2018. Young athletes return too early to knee-strenuous sport, without acceptable knee function after anterior cruciate ligament reconstruction. https://doi.org/10.1007/s00167-017-4747-8.

Buckthorpe, Matthew & Della Villa, Francesco 2019. Optimising the ‘Mid-Stage’ Training and Testing Process After ACL Reconstruction. https://doi.org/10.1007/s40279-019-01222-6.

Cronström, Anna, Tengman, Eva & Häger, Charlotte 2023. Return to Sports: A Risky Business? A Systematic Review with Meta-Analysis of Risk Factors for Graft Rupture Following ACL Reconstruction. https://doi.org/10.1007/s40279-022-01747-3.

Davies, George, McCarty, Eric, Provencher, Matthew & Manske, Robert 2017 ACL Return to Sport Guidelines and Criteria doi: 10.1007/s12178-017-9420-9

Du, Tianshu, Shi, Yanru, Huang, He, Liang, Wei & Miao, Danmin 2022. Current study on the influence of psychological factors on returning to sports after ACLR. DOI: 10.1016/j.heliyon.2022.e12434.

Escamilla, Rafael F, Macleod, Toran D, Wilk, Kevin E, Paulos, Lonnnie, Andrews, James R 2012. Cruciate ligament loading during common knee rehabilitation exercises. DOI: 10.1177/0954411912451839

Grindem, Hege, Snyder-Mackler, Lynn, Moksnens, Håvard, Engebretsen, Lars & Risberg, May Arna 2016. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. DOI: 10.1136/bjsports-2016-096031.

Kostifaki, Roula, Korakakis, Vasileos, King, Enda, Barbosa, Olivia, Maree, Dustin, Pantouverism , Michail, Bjerregaard, Andrreas, Luojomaki, Julius, Wilhelmsen, Jan, Whiteley, Rodney 2022. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. DOI: 10.1136/bjsports-2022-106158

McPherson, April, Feller, Juliana, Hewett, Timothy & Webster, Kate 2019.Psychological Readiness to Return to Sport Is Associated With Second Anterior Cruciate Ligament Injuries https://doi.org/10.1177/0363546518825258

Rambaud, Alexander JM, Arden, Clare L & Thoreux, Patricia, Regnaux, Jean-Philippe, Edouard, Pascal 2017. Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review. DOI: 10.1136/bjsports-2017-098602

Webster, Kate E & Feller, Julian A 2019. Expectations for Return to Preinjury Sport Before and After Anterior Cruciate Ligament Reconstruction. DOI: 10.1177/0363546518819454

Wong, Choi-Yan, Mok, Kam-Ming & Yung, Shu-Hang 2023. Secondary Anterior Cruciate Ligament Injury Prevention Training in Athletes: What Is the Missing Link? https://doi.org/10.3390/ijerph20064821.

Zarzycki, Ryan, Cummer, Kathleen, Arhos, Elanna, Failla, Mathew, Capin, Jacob, Smith, Angela & Snyder-Mackler, Lynn 2023. Female Athletes with Better Psychological Readiness Are at Higher Risk for Second ACL Injury After Primary ACL Reconstruction. https://doi.org/10.1177/19417381231155120