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RETURN TO HIGH LEVEL PLAY AFTER ACL RECONSTRUCTION
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steroid is appropriate. Steroid must not be used
to progress a player towards play however and
is simply rather used to calm the knee down to
allow resolution of effusion for a period of
relatively low loading to regain muscle strength
and neuromuscular control before proceeding
again some weeks later.
In my career cases in which all seemed to be
well apart from an effusion have been
associated with premature graft re-rupture.
Swelling has to be respected.
Factor Three: Aerobic Fitness
It seems obvious that allowing athletes who are
aerobically unfit to play is a risk. They will
fatigue quickly and lose neuromuscular control,
which will put them at risk of graft re-rupture.
Aerobic fitness is easily measured with
functional testing and tests such as a VO
2
Max.
Factor Four: The Concept of Limb
Symmetry
This concept embodies the theory that normal
neuromuscular control in the limb will protect
ACL graft.
Some athletes will have jump/land mechanics
that are putting them at risk of ACL injury.
These need to be corrected during the rehab
process of course. This is particularly true of
female athletes who have a tendency to land
with valgus and external rotation, even in the
uninjured limb.
I explain to the players that they should have
limbs with sufficient muscular symmetry that I
find it hard to judge which was the knee that
was operated upon. They can have their
muscle strength tested with isokinetic testing
and have functional testing such as hop
heights, hop distance and star excursion
measured. Prior to return to play I aim for a
deficit of less than 5% side to side. I also
explain that none of the tests we do are perfect
since they cannot replicate true on-field play.
Nevertheless they, of course, provide helpful
evidence to justify return to play.
Factor Five: Timing
Whilst anecdotally I have had many players
return ahead of schedule I realise this is not
something that should be encouraged since the
majority of players will be at risk if they do this.
Factor Six: Graft Maturation
The reality is that we have no firmunderstanding
of the biology of graft healing. It would be
logical to suggest that the fastest healing within
the bone tunnel would be to blocks of a
quadriceps tendon or patellar tendon. It is
likely that the quality of soft tissue healing in
these grafts is also better as they have a natural
attachment to their bone blocks. It would also
be logical to think that the slowest healing of
all would be withAllograft. The truth is that the
proof of this is lacking. We can only really
guess at the various stages of healing presuming
an initial graft degradation followed by
revascularization and subsequent ligamenti
sation with the laying down of collagen. The
only judge of the healing process is clinical
examination, the presence or absence of an
effusion, instrumented laxity testing, stress
radiographs, or MRI appearance. MRI scans
report the signal of the graft with a dark black
appearance indicating good healing and a pale
appearance indication oedema in the graft.
Unfortunately we do not have firm data as to
how this can guide is with regards to timing of
return to play. Perhaps a pale graft should delay
return to play and reduce loading durng the
rehabilitation period. When a loose ACL is
obvious by clinical examination, it is too late to
make any adjustments to the graft itself. Adding
a lateral tenodesis in some cases could be
justified, but practically it would be best to
encourage an athlete to accept a slower return
to play hoping that better neuromuscular
control after a longer rehabilitation period
could allow the player to cope dynamically
with their ACL laxity.