Set Realistic Expectations Following Sports Surgery
“She’s retorn her ACL? How could that possibly happen? Well, let’s get it fixed, she has more college showcases in six months.” In sports today, there are three unfortunate realities on a collision course: • focus on single sport specialization, • increased competitive exposure time, • and the adoption of a professional sports model for youth and recreational athletics. All of these place athletes at higher injury risk.
Another issue is the growing public assumption — fueled by the lay press and medical marketing — that whatever is broken can be fixed as good or better than it was. With regard to anterior cruciate ligament injuries we need to take a step back and recognize a slightly different reality.
Yes, through ongoing research orthopaedic surgeons are improving the understanding of ACL function and best practices for injury prevention, treatment, and rehabilitation. We are also more diligent and closely following our post-operative ACL patients over time to see how they do. Unfortunately, it is not as good as we have all hoped. ACL reconstruction does still provide the best option for return to jump, cut, twist, and turn sports. But even in the best of hands, many patients will develop progressive arthritis, decrease their levels of participation and require at least a year to eighteen months before returning to “normal” participation.
Most patients and their families assume that a simple outpatient surgery and a short course of rehabilitation will have the athlete back at pre-injury levels in six months. However, recent comprehensive reviews have found that less than one third of recreational athletes are back to competitive sports a year following their surgery and that only 50 percent will return to pre-injury levels of participation at 2–7 years post surgery. Why this disconnect?
• Success stories among athletes are promoted and most athletes and their families feel if they work hard enough they will be successful. Unfortunately, players who don’t make it back can slip away from view.
• Recreational athletes are often comparing their situation to that of high level collegiate or professional athletes. These athletes have different core sporting abilities, lifelong training habits, and unlimited resources that improve their postoperative and return to play situations. Still less than two thirds of NFL players will return to regular participation after ACL reconstruction.
• Until recently research has characterized surgery as being successful if repeat surgery was not required. We have not done a good job at recognizing that many post surgical patients decrease their level of activity and avoid higher demand athletics because of knee symptoms or fear of repeat injury upon return to participation.
• The public assumes that ACL injuries are all the same. This isn’t the case some ACL injuries also include other parts of the knee or surrounding areas. Athletes and their families need to recognize the following:
1. The major risk factor for ACL tears is participation in high demand jump, cut, twist, turn sports. It is not appropriate to have an ACL injured athlete in an environment in which the knee is constantly buckling or giving way.
2. Children and adolescents are at a higher risk of re-injury after ACL reconstruction.
3. Talking with an orthopaedic sports medicine specialist allows you to discuss realistic expectations following ACL injury and subsequent surgery.
4. Realize that surgical and rehabilitative successes with return to full activities are attainable goals but that re-injury or failure to return to pre-injury levels of participation can occur even in the best of situations.
5. Most importantly, make the athlete’s knee health the priority, not secondary to athletic participation or gains.
References Ardern, CL. Return-to-Sport Outcomes at 2 to 7 Years After Anterior Cruciate Ligament Reconstruction Surgery. Dunn, WR. Predictors of Activity Level 2 Years After Anterior Cruciate Ligament Reconstruction (ACLR). Reinhardt, KR. Revision ACL Reconstruction in Skeletally Mature Athletes Younger than 18 years. Ardern, CL. Return to sport following cruciate ligament reconstruction surgery: a systematic review and metaanalysis of the state of play. Shah, VM. Return to Play After Anterior Cruciate Ligament Reconstruction in National Football League Athletes.