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INTRODUCTION
Having undertaken a good operation there has
to be a decision made as to when it is safe to
return to play. A premature return to play prior
to restoration of satisfactory neuromuscular
control to a limb will put the good surgery at
risk of failure with graft re-rupture. I think it is
correct to say that most surgeons involved in
dealing with elite athletes, such as myself, try
to extend the recovery time to return to play to
be longer and longer! Most graft re-ruptures in
elite sport occur with return to play around
6-7 months post surgery. It is likely that the
“knee” matures for around 18 months following
ACL reconstruction. As a result it is illogical to
return all players to play at the same point in
time as each is ready at a different time. Apart
from insisting on minimum safe times, using a
time-dependent return to play is risky.Although
the biological healing of a graft may have
completed prior to 18 months, the fine-tuning
of neuromuscular control takes a very long
time; in truth it is probably never entirely
normal. Nevertheless, with structured
rehabilitation and maintenance drills, safe
function is to be expected as long as certain
criteria are met.
Nowadays when I meet an athlete for the first
time who has an uncomplicated ACL rupture I
explain that my aim for them is to return to play
between six and nine months from surgery. I go
on to tell them that when I was younger I would
say to my players confidently: “you will be
back in six months” - but with experience I
have learnt it often needs to be longer than that,
and some individuals take as long as a year.
Obviously if there are other factors such as
significant chondral lesions and other ligament
tears etc. the recovery should be expected to be
slower. Generally, I don’t use allograft, but it
would seem logical that these grafts need far
longer to mature than autograft. Also there
would be logic (but no proof) that hamstring
grafts may need longer than patellar tendon
grafts. Some individuals are prone to ACL
rupture and therefore also re-rupture of ACL
grafts due to factors such as malalignment, a
strong family history, being skeletally
immature, or being abnormally lax. It is
important to identify these patients and insist
on a longer return to play. In elite sport this is
rarely a concern in senior established players as
the process of “natural selection” means that an
ACL tear in this group is actually a relatively
rare injury. However in the young age group it
is a real issue.
I support the “traffic light” concept, popularised
by “Isokinetic”, to govern progress in
rehabilitation. A player cannot move on to the
next level of rehabilitation if they are not
safely, and without difficulty, completing tasks
RETURN TO HIGH LEVEL PLAY
AFTER ACL RECONSTRUCTION
A. WILLIAMS