Post-ACLR Reinury Rates.
Updated: Apr 25
"Sports medicine is about getting people back to the sport they love, keeping them in the sport they love and doing it the right way” – Dr. James R. Andrews.
Sports medicine is designed to help athletes recover from injuries and return to their sports safely and effectively. Its aim is to improve an athlete's recovery process, develop injury prevention strategies and ensure athletes can maintain their performance levels post-injury.
In the context of anterior cruciate ligament reconstruction (ACLR) this includes advancements in surgical techniques, rehabilitation protocols and return-to-play criteria. Even so, taking all this into account, meeting all the recovery criteria does not guarantee that an athlete will not suffer a reinjury.
It does, however, significantly reduce the risk.
Level I Sports.
It’s worth to note that different reinjury rates numbers will change based on the athletic population being studied. They can additionally differ depending on factors such as type of sport, the individual physical condition and rehabilitation protocols. On average, reinjury rates for competing athletes range between 5% and 20% after returning to their respective sports.
It is difficult to pinpoint a specific sport with the highest reinjury rate after ACLR. Yet, sports with a higher overall risk of ACL injuries and reinjuries, called 'level one sports', are typically those that involve frequent cutting, pivoting and sudden changes of direction as well as high defensive and offensive impact forces during the game.
These sports often include: football, basketball, skiing, handball and volleyball.
Other factors.
Situation is worse in case of young players, where almost 25% of individuals who are of a younger age (<25 yo) and return to a level I sport will either reinjure the reconstructed ACL or injure the opposite side. Factors contributing to this include their ongoing physical development, a relatively early sports specialisation and unrealistic drive for return to play quickly.
Gender is another factor that can contribute to higher reinjury rates in athletes after ACLR. Female athletes have been found to be at a higher risk of reinjury after ACLR compared to male athletes, likely due to anatomical, hormonal and neuromuscular factors.
Moreover, females have a greater proportion of second injury to the contralateral (opposite) ACL (62%), whereas second reinjury in case of males seems to occur more often to the reconstructed ACL graft (75%).
Outmost fact to recall is the scale of emotional drama experienced by athletes after the knee damage. Regardless of first or future injuries, the threat that 15% of all athletes dealing with ACL-related injuries will permanently leave the sport they are passionate about, is still present.
Visual of the theoretical consideration of op-limb compared to non-op and pre-op performance levels suited for the timeline of traditional rehabilitation model showing the abstract inconsistency (gap) of the sport-specific needs (expectations) compared to the reported outcomes (reality).
It's worth noting that capturing the 'gap' may reach beyond the quantitative metrics obtained conventionally in the clinical and gym settings, suggesting that other factors regarding neuromuscular and skill-specific conditioning, i.e. horizontal forces exposition, lack of motor control on the neuromuscular level and persistent prediction errors due to athlete's emotional state may also contribute to the whole picture of RTS readiness.
Prevention Strategies.
There is an urgent need to identify practical and evidence-based solutions.
The suspected 'gap' between the anticipated outcomes of the rehabilitation and the actual effects of methods used in standard sports medicine creates a challange where reason should work together with innovation.
To enhance the current state-of-the-art in professional rehabilitation and reduce the still significant hazard of subsequent injuries following ACLR, medical professionals and sports staff should consider further advancements in reconstruction techniques and rehabilitation protocols along with an integrative cooperation under a unified framework of return-to-play process.
In particular, these consist of:
Asking the right questions about what constitutes the 'gap' of performance.
Keeping an injured athlete in rehab training until <9 mo after surgery, despite the satisfying outcomes being documented and correcting the most relevant deficits, apparently in the matter of motor control.
Integrating of conventional strength exercises with neuromuscular and sport-specific skill training within collaborative framework with reference to physician, physio and S&C coach responsibilities.
Implementing the injury prevention programs, which might be crucial in collision sports, to prepare for potentially harmful situations of running, falling, assaulting and defending (worst case scenarios).
Finding a replicable consensus in the medical community regarding objective criteria that is required before athletes are released to full sports participation after ACLR, especially concerning the utilisation of clinical assessment, testing batteries, dynamometrics and available normative data.
Imagination an athlete's emotional collapse as they confront another injury in their career.
Take-Home Message.
Adequate maintenance of performance levels after ACLR aimed at fulfilling the specific requirements of a given sport may contribute to the significant reduction of future reinjury rates in athletes.
Medical and sporting staff should seek further advancements in surgical techniques and return-to-play criteria, apart from the apparent need of better cooperation within the clinical environments.
Much work remains to bridge the still apparent inconsistency between theory of conventional rehabilitation used worldwide and the reality of still apparent reinjury rates in the athletic population, especially in terms of highly-vulnerable athletic youth.
This article is published for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice.
Further Reading.
Barber-Westin et al. One in 5 Athletes Sustain Reinjury Upon Return to High-Risk Sports After ACL Reconstruction: A Systematic Review in 1239 Athletes Younger Than 20 Years. Sports Health (2020).
Shelbourne KD et al. Incidence of Subsequent Injury to Either Knee Within 5 Years After Anterior Cruciate Ligament Reconstruction with Patellar Tendon Autograft. American Journal of Sports Medicine (2009).
Paterno MV et al. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. American Journal of Sports Medicine (2014).