S. Keays1,2, D. Mellifont1, M. Sayers1, M. Stuelcken1, A. Keays3
1The University of the Sunshine Coast, School of Health and Sports Sciences, Sunshine Coast, Australia, 2Private Physiotherapy Practice, Sunshine Coast, Queensland, Australia, 3Private Orthopaedic Practice, Sunshine Coast, Queensland, Australia
Background: Two million sportspeople rupture their ACL annually and the number continues to increase especially in adolescent athletes. ACL reconstruction is considered to provide the best chance of return to sport (RTS) but a recent study has shown that only 58% return to their original sporting level thus questioning of the superiority of surgery. Recently, 68.1% RTS was reported in both surgical and non-surgical groups one-year post-surgery.
Purpose: This study aimed to compare long-term RTS between surgical and non-surgical groups.
Methods: 111 patients from a cohort of 330 referred for physiotherapy were involved: 55 managed conservatively and 56 managed surgically. The non-surgical group was 12 years post-injury, mean aged 41years, 34 males and 21 females. The surgical group was 10 years post-injury (six years post-surgery) mean aged 33 years, 39 males and 17 females. ACL rupture was diagnosed on clinical testing, MRI or arthroscopy. Patient assessment included clinical stability testing, KT1000, subjective stability testing, isokinetic quadriceps and hamstring strength. RTS was scored on a 6-point scale. RTS differences between groups were assessed using chi squared tests and Spearman’s rho assessed the relationship between RTS and outcome measures.
Results: There was a high RTS rate in both groups: 89% in non-surgical group and 96% in surgical. In the non-surgical group 11% did not RTS, 18% returned to safe sports, 9% returned to running, 29% to sports involving limited twisting, 22% to social pivoting sports and 11% to competitive pivoting sport. In the surgical group the respective percentages were 4%, 9%, 12%, 16%, 14% and 45%. The striking difference was the higher return to competitive pivoting sports in the surgical group (p<0.002). However, 5 surgical patients had ruptured their contralateral ACL and two had chosen to stop pivoting sports at the time of follow-up. Most conservatively managed patients had modified their sport. Their level of return sport correlated highly with the level of quadriceps and hamstring strength of the injured side (r=.644 and r=,701; p<0.001) as well as their subjective stability (r=.404; p=0.002). The level of return sport in the surgical group correlated with subjective stability (r=.353; p=0.012) and the side-to-side KT 1000 measures (r=-.473; p<.001). With both groups combined the RTS levels correlated with all stability and strength measures.
Conclusion(s): RTS in both groups was pleasing. The ability to RTS correlated with strength and stability measures. In particular, in the non-surgical group the RTS level correlated with quadriceps and hamstring strength. This study confirms that surgery provides the best opportunity for return to pivoting sport especially at a competitive level. However, more subsequent ligament injuries occurred in this group. Knee osteoarthritis may become more prevalent in the surgical group as a result of the higher sporting expectations and rotational demands made of the ACL-reconstructed knee. Ongoing research is investigating this.
Implications: ACL reconstructive surgery is recommended for patients who rupture their ACL and wish to return to competitive pivoting sports. Strength and stability training should be maximised in all patients.
Funding, acknowledgements: No funding provided.
Keywords: anterior cruciate ligament, Return to sport, surgical versus non-surgical
Topic: Sport & sports injuries
Did this work require ethics approval? Yes
Institution: The University of Queensland
Committee: Human Research Ethics Committee
Ethics number: 2008000964
All authors, affiliations and abstracts have been published as submitted.
