Sports performance following ACL reconstruction

I’ve written quite a bit in the past about ACL injury; at-risk age groups, risk factors, when is it safe to return to sport following ACL surgery and ACL prevention programs – just to name a few (see blog for past posts - https://www.mickhughes.physio/#!blog/a7skm) . This time however, I’m turning my attention to sport performances upon return to sport.

It has been previously reported that 80% of people will return to some form of sport, 65% will return to the same sporting level, and 55% will return to competitive sports within 1-2 years following ACL reconstruction (8). That’s all well and good, but what I'm interested in is, Are the return to sport statistics the same at the elite level, and importantly for the fans, will the athlete ever be the same again when they get back on the sporting field?

I posted a couple of times last week on social media about elite player performance following ACL reconstruction (ACLR). In one study it was found that 86% of NBA players successfully made a comeback in the next playing season, but total games started, total games played and player efficiency ratings were all significantly lower in their first season back compared to age-matched controls. Their careers were almost 2 years shorter as well (1).

Conversely, I also wrote about the rise and rise of Australian Cricket test batsman Usman Khawja, after he recently returned to sport following ACLR. Prior to his ACL injury in late 2014, he was in-and-out of the Australian test team, and had a test batting average of 24 runs per innings. However, only 10 months after sustaining his injury, he was picked for the Australian test team, scored 170+ runs in his first match back, and has been averaging over 100 runs per innings ever since.

The obvious difference between these 2 case studies is that the physical requirements and tightly packed playing schedules in the NBA requires the knee to function significantly greater than what is required for test-match cricket. Nevertheless, I was Intrigued as to how one cohort of players can experience declines in performance after ACLR, and one cohort of players can seemingly thrive, so I went looking for more information and found some interesting results:

 MLS Soccer players: (2)

• 77% players RTS around 10 months post-op
• 10% re-injury rate
• Average career length after ACLR was 4 years
• ACL surgery had no significant effect on player performance in post-op follow-up period

NFL players #1: (3)

• 82% of 559 athletes returned to sport after ACL at average of 378 days (>12 months).
• Career length following ACLR was only 1.6 years
• ACLR led to significantly worse performances in the first 3 seasons upon RTS (if able to continue to play that long)

NFL players #2: (4)

• 63% RTS around 10 months post-op.
• Those that did return to sport played a significantly more amount of games prior to injury (ave 50) vs those that didn’t (ave 28).
• Players that were drafted in the first 4 rounds were 12x more likely to RTS, rather those drafted in rounds 5-7.
• Interesting conclusion that highly skilled and experienced athletes more likely to return to NFL than those that aren’t as skilled or have as much playing experience

NHL players: (5)

• 97% players RTS at 7.8 months post-op.
• Re-injury rate was only 2.5%.
• Players that did RTS, played another 4.5 years post-op.
• Performance measures actually increased in ACL patients than age-matched player controls (mean goals and points per season, mean power play and strength goals per season, and mean shots and shooting percentage per season)

NBA and NFL combine athletes: (6) (7)

• Past ACL surgery does not affect performance on key performance tests during both the NBA and NFL combine of speed, agility and jumping when compared to other athletes who have not torn their ACL.

So there you have it, a bit of a mixed bag of successful and less successful return to sport performances across a number of different sporting codes.

Being an eternal optimist, I guess the moral of my story today is that: Despite what the research shows for NBA players and NFL players, ACL injury doesn’t have to mark the start of a slow and steady decay in player performance and an early retirement from the game. In fact, in some sports, an ACL injury to an athlete can be the catalyst to spark or revive their career. The time spent on the sidelines and sitting in rehab allows them to work on the weaknesses in their game, not to mention work hard on their strength, power, agility, balance and speed so that they can come back, fitter, stronger and faster than ever before.

And that is simply just a joy to watch!

References:

1. Kester BS, Behery OA, Minhas SV, Hsu WK. Athletic performance and career longevity following anterior cruciate ligament reconstruction in the National Basketball Association. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2016 Mar 12. PubMed PMID: 26971105. Epub 2016/03/14. Eng.
2. Erickson BJ, Harris JD, Cvetanovich GL, Bach BR, Bush-Joseph CA, Abrams GD, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in Male Major League Soccer Players. Orthopaedic journal of sports medicine. 2013 Jul;1(2):2325967113497189. PubMed PMID: 26535238. Pubmed Central PMCID: PMC4555483. Epub 2013/07/01. eng.
3. Mai HT, Alvarez AP, Freshman RD, Chun DS, Minhas SV, Patel AA, et al. The NFL Orthopaedic Surgery Outcomes Database (NO-SOD): The Effect of Common Orthopaedic Procedures on Football Careers. The American journal of sports medicine. 2016 Jun 16. PubMed PMID: 27311414. Epub 2016/06/18. Eng.
4. Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. The American journal of sports medicine. 2010 Nov;38(11):2233-9. PubMed PMID: 20610771. Epub 2010/07/09. eng.
5. Erickson BJ, Harris JD, Cole BJ, Frank RM, Fillingham YA, Ellman MB, et al. Performance and Return to Sport After Anterior Cruciate Ligament Reconstruction in National Hockey League Players. Orthopaedic journal of sports medicine. 2014 Sep;2(9):2325967114548831. PubMed PMID: 26535359. Pubmed Central PMCID: PMC4555634. Epub 2014/09/01. eng.
6. Mehran N, Williams PN, Keller RA, Khalil LS, Lombardo SJ, Kharrazi FD. Athletic Performance at the National Basketball Association Combine After Anterior Cruciate Ligament Reconstruction. Orthopaedic journal of sports medicine. 2016 May;4(5):2325967116648083. PubMed PMID: 27294169. Pubmed Central PMCID: PMC4887878. Epub 2016/06/14. eng.
7. Keller RA, Mehran N, Austin W, Marshall NE, Bastin K, Moutzouros V. Athletic Performance at the NFL Scouting Combine After Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 2015 Dec;43(12):3022-6. PubMed PMID: 26493338. Epub 2015/10/24. eng.
8. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine. 2014 Nov;48(21):1543-52. PubMed PMID: 25157180. Epub 2014/08/27. eng.