Return to sport after anterior cruciate ligament reconstruction in professional soccer players

doi:10.1016/j.knee.2014.02.005

The Knee

Volume 21, Issue 3, June 2014, Pages 731-735

https://doi.org/10.1016/j.knee.2014.02.005 Get rights and content

Abstract

Background

To investigate time to return to sport and rate of professional sport activity in a homogenous group of competitive soccer players 4 years after anterior cruciate ligament (ACL) reconstruction and rehabilitation.

Methods

Twenty-one male professional soccer players (mean age 22.9 ± 5.4 years) underwent non-anatomical double-bundle autologous hamstring ACL reconstruction and followed the same rehabilitative protocol. Clinical evaluation was performed preoperatively and at 3, 6 and 12-month follow-up. Data regarding return to train and official match, sport activity, complications and revision surgeries were collected at 4-year follow-up.

Results

Laxity test (KT-2000) and total KOOS mean score resulted in a significant improvement from the preoperative status to the 12-month follow-up (p < 0.0001). The KOOS mean value showed a significant progressive improvement from the preoperative status to 6-month follow-up (p = 0.0010) as well, while values collected at 6 and 12-month follow-up were comparable (p = 0.2349). Returned to official matches 186 ± 53 days after surgery. After 12 months, 95% came back to the same activity level performed before injury. Four years after ACL reconstruction, 15 patients (71%) were still playing competitive soccer. One patient (5%) underwent ACL failure and subsequent revision.

Conclusions

The ACL reconstruction with the presented technique followed by patient-tailored rehabilitation, allowed 95% and 62% professional male soccer players to return to the same sport activity 1 year and 4 years after surgery respectively. However, 71% were still able to play competitive soccer at final follow-up. Clinical scores were restored after 6 months.

Level of evidence: IV, case series.

Introduction

The time to return to play and the ability to continue sport activity with time are two important outcomes after anterior cruciate ligament (ACL) reconstruction, especially in young sportsmen. Nevertheless no consensus is available regarding the optimal rehabilitation length [1] and the return to play definition [2]. These issues are more controversial when considering the outcomes related to single sports. In 2011 a systematic review by Warner et al. [3], evaluating sport-specific outcomes after ACL reconstruction, reported only three studies presenting the results in soccer players [4], [5], [6]. The authors concluded that “identifying sport-specific differences in ACL reconstruction outcomes in athletes could lead to more effective rehabilitation programs for all these athletes after surgery” and it will “provide orthopedic surgeons the ability to accurately inform patients about what they should plan to expect after surgery in terms of performance level and timing of return to sport” [3], thus underlying the need for further sport specific studies. Furthermore, different interpretations have been attributed to the “return to sport” outcome, ranging from return to perform sport-specific gestures, restore pre-injury activity level, return to train or return to official match. Often, the precise definition is not even reported.

The main objective of this study was to report the time to return to sport after ACL reconstruction in a homogenous group of competitive football players treated with the same surgical technique and rehabilitative programme and the rate of sport activity four years after the surgery.

Section snippets

Material and method

Between January and June 2009 all the patients satisfying the following inclusion criteria were enrolled in the study:

•
ACL lesion; and
•
male professional soccer player, involved in competitive sport activity more than 4 days per week on regular bases and attending the main divisions of Italian Soccer League.

Exclusion criteria were:

•
posterior cruciate ligament (PCL) lesion;
•
grade III medial collateral ligament (MCL) lesion;
•
lateral collateral ligament (LCL) lesion;
•
unstable contralateral knee;
•
systemic

Results

All patients (100%) were available for on-going clinical evaluations and at the 4-year follow-up. The mean age at time of surgery was 22.9 ± 5.4 (Table 1). Four patients (19%) had a history of medial or lateral partial meniscectomy on the interested knee and three (15%) of contralateral ACL reconstruction, while 12 patients (57%) underwent at least one concurrent procedure combined to ACL reconstruction (Table 2).

The side-to-side difference in manual maximum displacement test performed with a

Discussion

In the present study the outcomes of a homogenous group of male professional soccer players, who underwent ACL reconstruction with the same technique and rehabilitative protocol, are presented using a validated clinical score and precise definition of “return to sport”. Regarding the latter outcome, a 2011 meta-analysis of Arden et al. [10] reported 7.3 (range 2–24) months as the mean time needed to return to sport in general population, even though different end-points were used. Few studies

Conclusions

The ACL reconstruction with non-anatomical double-bundle hamstring technique, combined with a patient-tailored target-based rehabilitation, allowed 95% and 62% of professional male soccer players to return to the same professional sport activity 1 year and 4 years after surgery respectively. However, overall, 71% were still able to play competitive soccer at any level at final follow-up. The clinical scores were restored to pre-injury status since 6 months, while return to play in official match

Conflict of interest

The authors declare no personal or financial conflict of interests during the study execution and manuscript preparation.

Acknowledgment

The authors are grateful to Costanza Musiani, MD and Giada Lullini, MD for their support.

References (16)

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Sport-specific outcomes after anterior cruciate ligament reconstruction
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Anatomic double-bundle anterior cruciate ligament reconstruction with hamstrings
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S. van Grinsven et al.
Evidence-based rehabilitation following anterior cruciate ligament reconstruction
Knee Surg Sports Traumatol Arthrosc
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S. Della Villa et al.
Clinical outcomes and return-to-sports participation of 50 soccer players after anterior cruciate ligament reconstruction through a sport-specific rehabilitation protocol
Sports Health
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H. Roos et al.
Soccer after anterior cruciate ligament injury—an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players
Acta Orthop Scand
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High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes
Ann Rheum Dis
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Anterior cruciate ligament injury in elite football: a prospective three-cohort study
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Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up
Knee Surg Sports Traumatol Arthrosc
(2011)

There are more references available in the full text version of this article.

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Although current rehabilitation protocols following anterior cruciate ligament reconstruction (ACLR) are based on the graft remodeling process, there is uncertainty about its time schedule. Moreover, there are individual differences in neuromotor learning and flexibility after ACLR. The current study was conducted to investigate the functional outcomes of the criterion-based rehabilitation protocol in amateur athletes following ACLR.
Fifty amateur male athletes who had ACLR were assigned randomly into two equal groups. The experimental group received a criterion-based rehabilitation protocol. The control group received a conventional physical therapy program. Both groups had five treatment sessions per week for six months. The primary outcome was pain intensity measured by VAS. Secondary outcomes included functional assessments measured by the limb symmetry index (LSI) of the hop test battery, knee effusion, and the Knee injury and Osteoarthritis Outcome Score (KOOS).
Mixed-design-MANOVA indicated significant treatment, time, and treatment × time interaction. The interaction was significant for all outcome measures in favor of subjects who received a criterion-based rehabilitation protocol. Within-group analysis revealed a significant reduction in pain in both groups and improvements in all variables related to the KOOS or LSI of the hop test battery. Knee effusion was significantly reduced post-treatment in patients who received a criterion-based protocol when compared to their controls.
Although application of a criterion-based rehabilitation protocol for 6 months after ACLR is more effective than a conventional program, its duration should be expanded beyond this period to allow patients to reach their return to play goals.
Treatment of ACL injury in a professional soccer player during COVID-19 lockdown
2022, Apunts Sports Medicine
Anterior Cruciate Ligament (ACL) injuries stand out as the most severe in sports such as soccer. This study presents the rehabilitation process of a professional soccer player who suffered a total ACL tear. It details the treatment performed after the surgical intervention and all the adaptations that had to be applied in the rehabilitation process due to the lockdown period established at the beginning of the COVID-19 pandemic. During the period comprised between weeks 9 and 21 post-surgery, the rehabilitation treatment was carried out virtually, adapting the actions, work environment and equipment used. Despite the limitations it entailed, the virtual format and the adaptations in the treatment allowed the rehabilitation process to continue, fulfilling all the pre-established objectives and deadlines with a consequent satisfactory and safe return to competitive sport. After carrying out a bibliographic research, no clinical cases have been found regarding the adaptation of the rehabilitation process of an ACL reconstruction in a professional soccer player during the COVID-19 lockdown.
Relationship between lower limb EMG activity and knee frontal plane projection angle during a single-legged drop jump
2021, Physical Therapy in Sport
Citation Excerpt :
Studies have found ACL injury rates of 0.45 and 1.17 per 1000 athlete exposures (AEs) in collegiate male and female soccer players respectively, and 0.80 and 2.12 per 1000 AEs in collegiate male and female basketball players (Anderson et al., 2019). ACL injuries can have consequences such as six to nine months' time lost, not returning to the previous competitive level, or early osteoarthritis with a significant impact on the athlete's health and performance (Lohmander et al., 2007; Waldén et al., 2016; Zaffagnini et al., 2014). One of the most common injury mechanisms to suffer an ACL injury is the dynamic knee valgus during sports maneuvers, such as single-legged landing after a jump (Bisciotti et al., 2019; Pfeifer et al., 2018).
To assess a relationship between lower limb muscle activity and the frontal plane knee kinematics during a single-legged drop jump.
Correlation study;
Functional Anatomy Laboratory.
35 healthy collegiate male athletes.
Muscle activity (%MVIC) of gluteus maximus, gluteus medius, biceps femoris, semitendinosus, vastus medialis quadriceps, vastus lateralis quadriceps, medial gastrocnemius and lateral gastrocnemius; peak knee frontal plane projection angle; and Pearson's correlation coefficients between muscle activity and peak knee frontal plane projection angle. All outcomes were assessed for both dominant and non-dominant limbs.
Significant correlations (r = 0.46–0.60, P < 0.05) were found between the muscle activities of the gluteus maximus, gluteus medius, biceps femoris, and semitendinosus, when compared to the knee frontal plane projection angle.
Gluteal muscles and hamstring muscles are associated with the peak knee frontal plane projection angle during a single-legged drop jump test. Thus, gluteal and hamstring muscle activities should be considered when developing rehabilitation or injury prevention programs.
Surgical therapy of anterior cruciate ligament injuries: reconstruction or primary repair and InternalBrace<sup>TM</sup> augmentation?- a narrative review
2021, Sports Orthopaedics and Traumatology
Die Anfänge der Kreuzbandchirurgie stellte die Naht über eine invasive Arthrotomie dar, was jedoch aufgrund einer hohen Komplikations- und Re-Rupturrate alsbald wieder verlassen wurde. Heutzutage ist der operative Goldstandard die arthroskopische VKB Rekonstruktion mittels autologem Sehnenmaterial. Diese Technik liefert reproduzierbare gute Resultate, ist jedoch auch mit einer Graftentnahme-Morbidität, vorderen Knieschmerzen und postoperativer Quadrizepsschwäche assoziiert. Die neuesten technischen Entwicklungen im Bereich der arthroskopischen Chirurgie haben daher das Interesse an der VKB Naht wiederbelebt. So wurden für die Naht und Augmentation mittels InternalBrace^TM gute klinische Ergebnisse beschrieben, jedoch bleibt die Literatur bislang noch den Beweis des funktionell-biomechanischen Vorteils dieser Technik schuldig.
While the beginnings of Anterior Cruciate Ligament (ACL) surgery comprised the direct suture of the torn ligament via an invasive arthrotomy, this approach has been swiftly abandoned because of high complication and re-rupture rates. Today, the gold standard is arthroscopic ACL reconstruction using autologous tendon material. However, although this technique results in reproduceable good outcomes, several postoperative complications such as graft harvesting site morbidity, anterior knee pain and quadriceps weakness have been reported. Recent technical developments in arthroscopic surgery have therefore resurrected the interest in primary ACL repair. While good clinical outcomes after primary ACL repair and InternalBrace^TM augmentation have been reported, supporting evidence for the functional benefit of this technique is still missing.
Return to sport after anterior cruciate ligament injury: Panther Symposium ACL Injury Return to Sport Consensus Group
2021, Journal of ISAKOS
A precise and consistent definition of return to sport (RTS) after anterior cruciate ligament (ACL) injury is lacking, and there is controversy surrounding the process of returning patients to sports and their previous activity level. The aim of the Panther Symposium ACL Injury RTS Consensus Group was to provide a clear definition of RTS after ACL injury and description of the RTS continuum, as well as provide clinical guidance on RTS testing and decision-making.
An international, multidisciplinary group of ACL experts convened as part of a consensus meeting. Consensus statements were developed using a modified Delphi method. Literature review was performed to report the supporting evidence.
Key points include that RTS is characterised by achievement of the preinjury level of sport and involves a criteria-based progression from return to participation to RTS, and ultimately return to performance. Purely time-based RTS decision-making should be abandoned. Progression occurs along an RTS continuum with decision-making by a multidisciplinary group that incorporates objective physical examination data and validated and peer-reviewed RTS tests, which should involve functional assessment as well as psychological readiness. Consideration should be given to biological healing, contextual factors and concomitant injuries.
The resultant consensus statements and scientific rationale aim to inform the reader of the complex process of RTS after ACL injury that occurs along a dynamic continuum. Research is needed to determine the ideal RTS test battery, the best implementation of psychological readiness testing and methods for the biological assessment of healing and recovery.
Does delayed onset muscle soreness affect the biomechanical variables of the drop vertical jump that have been associated with increased ACL injury risk? A randomised control trial
2021, Human Movement Science
Citation Excerpt :
In England the rate of public ACL reconstructions was 24.2 /100000 population in the years 2016–17 (Abram et al., 2020), while in the US the mean lifetime cost for a patient undergoing ACL reconstruction was $38,121 as of the year 2012 (Mather 3rd et al., 2013). ACL injury also has significant impact on an athlete's career with the period of rehabilitation taking up to 6–12 months (Notarnicola et al., 2016; Zaffagnini et al., 2014), and only 65% of individuals returning to their previous level of play (Ardern, Taylor, Feller, & Webster, 2014). The incidence and subsequent impact of ACL injury may be reduced by the identification of ACL injury risk factors, as this may help in the development of effective injury prevention interventions (Gagnier, Morgenstern, & Chess, 2013; Takahashi & Okuwaki, 2017).
Delayed onset muscle soreness (DOMS) and Anterior Cruciate Ligament (ACL) injuries are both prevalent in sport. It is currently unknown whether DOMS increases ACL injury risk.
This study aimed to provide preliminary insight on whether DOMS affects ACL injury risk by investigating whether DOMS affects the biomechanical variables of the DVJ that have been identified as risk factors for future ACL injury.
This was a randomised control trial involving 32 active individuals aged 18–35 years, with no history of ACL injury. Participants underwent two sessions of force-plate testing and 3D motion analysis of the drop vertical jump (DVJ). The DVJ was chosen as it has been investigated prospectively for association with future ACL injury. Initial testing was followed by randomisation to DOMS or control group. The DOMS group underwent a DOMS-inducing exercise protocol, the control group did not. Both groups were re-tested 48 h after initial testing. Five variables of the DVJ that have been associated with future ACL injury were chosen for analysis - peak knee flexion angle, peak vertical ground reaction force, ground contact time, peak knee abduction angle & peak knee abduction moment. Between-group differences were compared using a two-way mixed analysis of variance; alpha level set to 0.05.
DOMS was successfully induced in all participants of the DOMS group however no statistically significant group x time interactions were found for any of the five variables analysed.
DOMS did not affect the biomechanical variables of the DVJ that have been associated with future ACL injury. By extension, this may suggest that DOMS might not affect ACL injury risk. However, it is also possible that certain attributes of the DVJ meant that any effect of DOMS was simply unable to be quantified, even if an effect existed. All considered, our position is that conclusion cannot be drawn from this study alone on whether DOMS affects ACL injury risk. Further research is required.

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View full text

Return to sport after anterior cruciate ligament reconstruction in professional soccer players

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Material and method

Results

Discussion

Conclusions

Conflict of interest

Acknowledgment

Arthroscopy

Arthroscopy

Evidence-based rehabilitation following anterior cruciate ligament reconstruction

Knee Surg Sports Traumatol Arthrosc

Clinical outcomes and return-to-sports participation of 50 soccer players after anterior cruciate ligament reconstruction through a sport-specific rehabilitation protocol

Sports Health

Soccer after anterior cruciate ligament injury—an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players

Acta Orthop Scand

High prevalence of osteoarthritis 14 years after an anterior cruciate ligament tear in male soccer players: a study of radiographic and patient relevant outcomes

Ann Rheum Dis

Anterior cruciate ligament injury in elite football: a prospective three-cohort study

Knee Surg Sports Traumatol Arthrosc

Single-bundle patellar tendon versus non-anatomical double-bundle hamstrings ACL reconstruction: a prospective randomized study at 8-year minimum follow-up

Knee Surg Sports Traumatol Arthrosc