Existing literature is varied in the methods used to make this determination in the treatment of athletes who have undergone recent anterior cruciate ligament (ACL) reconstruction. Some authors report using primarily time-based criteria, while others advocate for physical measures and kinematic testing to inform decision-making. The goal of this paper is to elucidate the most current medical evidence regarding identification of the earliest point at which a patient may safely return to sport. The present review therefore seeks to examine the evidence from a critical perspective—breaking down the biology of graft maturation, effect of graft choice, potential for image-guided monitoring of progression and results associated with time-based versus functional criteria-based return to play—to justify a multifactorial approach to effectively advance athletes to return to sport. The findings of the present study reaffirm that time is a prerequisite for the biological progression that must occur for a reconstructed ligament to withstand loads demanded by athletes during sport. Modifications of surgical techniques and graft selection may positively impact the rate of graft maturation, and evidence suggests that imaging studies may offer informative data to enhance monitoring of this process. Aspects of both functional and cognitive testing have also demonstrated utility in prior studies and consequently have been factored into modern proposed methods of determining the athlete’s readiness for sport. Further work is needed to definitively determine the optimal method of clearing an athlete to return to sport after ACL reconstruction. Evidence to date strongly suggests a role of a multimodal algorithmic approach that factors in time, graft biology and functional testing in return-to-play decision-making after ACL reconstruction.
Level of evidence: level V.
- anterior cruciate ligament
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Contributors Significant contributions were made by each of the authors. DC: primary writing and revising of the manuscript. KE: contributed content and revisions to the paper, particularly to the biology and graft maturation sections. SWY: contributed content and revisions to the paper, particularly to the discussion on time versus criteria-based return to play. MD: contributed content and revisions to the paper, particularly to the imaging section. PKS: contributed content and revisions to the paper, particularly to the section on functional testing. MS: contributed significantly to the revisions of all sections of the paper. SS: contributed significantly to the organisation, planning and revisions of the paper, along with particular focus on the content of the graft choice section.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests SWY discloses research support, consultancy with Stryker and Smith & Nephew, and consulting fees with Stryker and Smith & Nephew. KE discloses he is Chair of ISAKOS Knee and Sports Preservation Committee and Vice General Secretary of ESSKA. SS is a board or committee member of AAOS, ACL Study Group, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, Epic Bio, International Cartilage Regeneration & Joint Preservation Society, International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine, Joint Restoration Foundation, and Vericel; on an editorial or governing board with the American Journal of Orthopaedics and Arthroscopy; a paid consultant for Arthrex, BioVentus, Sparta Biomedical, Reparel, NewClip, Ceterix Orthopaedics, Conmed, Flexion Therapeutics, GLG Consulting, Linvatec, Moximed, Olympus, RTI Surgical, Smith & Nephew, Vericel and Zimmer; a paid presenter or speaker for Arthrex, Conmed, Flexion Therapeutics, Joint Restoration Foundation, Smith & Nephew and Vericel; has stock or stock options with Vericel and Epic Bio; has IP royalties with Conmed; and receives research support from Arthrex.
Provenance and peer review Not commissioned; externally peer reviewed.
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