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A. WILLIAMS
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of the lower level. In this way those athletes
who are capable of a rapid safe return to play
can do so and avoid any unnecessary delay, and
will be separated from those who must need a
longer period to avoid a risky return too early.
Unfortunately despite much study in the area,
the decision as to when a player can return to
play remains uncomfortably inexact. I have
learned to customise my decision making
according to the patient, key milestones and
the graft choice. Due to the lack of consensus
and objective firm criteria a team approach
combining opinions of physios, team
physicians, and the surgeon is important.
“NEED TO KNOW” FACTS
1 -
The graft is dying or dead before healing and
rejuvenation.
2 -
The ACL cannot be as good as the natural
one, although statistically patients are more
likely to rupture the contralateral ACL than
re-tear the ipsilateral graft. Nevertheless if
they have torn their natural ACL, don’t forget
they can certainly tear their “new” one!
3 -
Knee joint proprioception will never be
the same again hence problems with mal-
alignment, or a suboptimalACL reconstruction.
MY DECISION MAKING
STRATEGY
When I am at the point of considering a return
to full training, and subsequent play, I use the
following factors to determine a return to play
time once a player has successfully completed
their rehabilitation period, and at a minimum of
6 months after surgery:
Factor One: Player Confidence
It seems logical that a player should not
compete until they are totally confident. There
is a problem with this criterion-many athletes
have achieved much in their careers by having
an abnormally positive attitude to play, even
despite “carrying” injuries. I therefore cannot
be persuaded by player confidence alone!
Alternatively, if a player lacks confidence this
usually reflects a significant deficit in their
readiness to play, and I take that very seriously.
Factor Two: The Dry Knee
An effusion is a reflection of either a problem or
that the knee is not ready for loading. Naturally
after any injury, and this includes surgery, there
will be an inflammatory response and fluid will
accumulate in the joint. In the longer term fluid
may persist if there is subtle instability in the
joint, chondral damage or mechanical issues
such as meniscal tears. It is essential to take an
effusion seriously since trying to continue with
activity whilst the knee is swollen can cause
permanent damage. The fluid is thin rather than
naturally occurring thick synovial fluid and is
therefore a poor lubricant and shock absorber,
plus it contains chemicals fromthe inflammatory
response that perpetuates the inflammatory
response and swelling. I also suspect the
inflammatory mediators soften the articular
cartilage. It is not uncommon for a player
working through an effusion to develop
subsequent chondral damage, such as in the
trochlear groove, related to the loading of
rehabilitation exercises. These situations are
very regrettable. A collaboration between
Fortius Clinic and The Kennedy Institute at
Oxford University has recently shown a
correlation following knee injury between
increased levels of various markers, especially
IL6, with low KOOS4 scores and improving
KOOS4 over time as the IL6 falls [1].
If effusions persist past three months into the
recovery I obtain an MRI scan and will often
undertake an arthroscopy if there is any
suspicion of a mechanical problem such as a
meniscal tear. If the chondral surface looks
healthy and there is no sign of meniscal
pathology then aspiration of the joint and
injection of PRP, or viscosupplement and some