June 12, 2024 • 25 mins
In this episode, we discuss early objective predictors of return to sport following ACL reconstruction. This conversation is particularly relevant for sports medicine fellows, physical therapists, athletic trainers, and orthopedic surgeons.
We explore a recent study focusing on the importance of early postoperative testing. Key points include the role of extension, strength, hop testing, and stability in predicting return to sport times.
Listeners will gain valuable insights into the significance of early rehabilitation metrics, the impact of objective testing on clinical decisions, and practical advice for improving patient outcomes. Tune in to learn how early intervention can lead to faster and more effective recovery for athletes after ACL surgery.
Follow us on (X) and Instagram @theskcpodcast, visit our SKC Podcast YouTube and Facebook pages, or email us at theskcpodcast@gmail.com
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:12):
And I'm here with Scott Bauman. And tonight we're going to be talking about
early objective predictors of return to sport time following anterior cruciate
ligament reconstruction, a topic that should be of interest to anyone interested in sports.
ACL return to play is always a hot topic, and we're going to talk about what
are some objective predictors early on in the rehabilitation process that can
give us an eye towards return to sport following ACL surgery.
(00:35):
Last week's episode was great. Dr. Fred Azar, one of my mentors from residency,
was on talking about the care of NBA athletes with knee injuries.
And that was a great conversation.
Sports Medicine Fellows, physical therapists, athletic trainers,
orthopedic surgeons, any of those groups that potentially could listen to this
podcast, go back and take a listen to Fred's episode.
(00:55):
He's a great resource and a real great resource for years of knowledge in sports
medicine and orthopedics in general.
And I think you'd learn something from that. If you'd like to find us on social
media, you can find us on our Facebook and YouTube channel at the Shelburne eCenter podcast.
You can find us on Instagram and Twitter at the SKC podcast.
(01:16):
And if you'd like to email us, you can email us at the SKC podcast at gmail.com.
So Scott, this is a study that you worked on in our office with Bill Clawson,
one of our physical therapists, along with myself and Dr.
Shelburne reviewing a lot of our ACL data to look at objective parameters.
And I think one thing that we do differently at our office that I think really
(01:36):
informs forms a lot of our decision-making is a lot of testing,
even really early, even the pre-surgery.
Phase of the patient's care, doing a lot of pre-surgical testing,
and then starting testing as early as a month, two months, three months on regular
intervals to follow where patients are doing with range of motion, with stability,
with strength, and a lot of those return-to-play criteria we're evaluating very early.
(01:59):
So with this study, we tried to look at those pretty early on and find out what
we could use as predictors.
So tell us a little bit about the background for this study and kind of how this study got started.
Sure. And like you said, we do have the unique opportunity to test these athletes
and these patients early on.
And this specifically is looking at the time of one to three months.
(02:21):
But because we have so much objective data and we have it in that early time
points, I think we are uniquely positioned to be able to look at a study of this nature.
And as far as the rationale, really a couple of different reasons.
The first of which is more internal with the treatment philosophy that we've
really been working off of for years with the Accelerated Rehabilitation program
after anterior cruciate ligament reconstruction that was really established by Dr.
(02:45):
Shelbourne in the early 90s. And the thought behind that is to really try to
work on restoring normal extension equal to the other side as quickly as possible.
And if we can get symmetric with their extension, that usually manifests itself
into normal strength a little bit quicker, and then naturally you're going to
get back to sports a little bit faster.
At least that's what we've been seeing over the years.
(03:07):
So we wanted to see, knowing that we've been working off this method of really
trying to hit the rehab early, really hit it hard pretty early by working on
those objective parameters.
We wanted to put it to the test and see, is there any predictive value in having
patients that achieve those goals early?
If they achieve them at one month versus two months versus three months versus
four months, what have you, is there going to be any differences in terms of
(03:31):
how quickly they're able to
return to sport based on those early measures that they're coming up with?
And then the second reason for the study is really just looking at the other
existing literature that's out there.
And everybody listening to this podcast that's read or done any research on
ACL reconstructions just knows
that the topic of return to sport can be controversial, first of all.
(03:53):
And second of all, it can be very, very multifactorial. I feel like most of
the studies that I look at that look on look at this topic really end with,
well, it's it's it's a multifactorial topic.
We can't for certain tell what is going to lead to return to sport.
And even further than that, are we measuring the right thing?
We go to these physical therapy meetings specifically where we're looking at
(04:15):
some of these objective tests later on as it pertains to return to sport.
And there's really a good discussion, not maybe pertaining to what the results
found. But, you know, talking with the authors of the study of,
you know, are we even measuring the correct thing? You know,
you break it down into strengthening.
Everybody agrees we need to measure strength, but how do we measure strength?
Do we measure strength with LSI?
Do we measure it compared to the other or compared to pre-op normal or normalize
(04:38):
it to body weight, what have you? So it's a pretty polarizing topic.
And I know a lot of the current literature is really towards the later stages
of rehab and how we test these athletes as it pertains to passing a criteria for return to sport.
So this is a little bit different, and we wanted to look at that early time
point to see if there's any predictive value of those measures as it pertained
(04:58):
to timing of return to sport.
Now, when it comes to testing, I think that's something that we do differently
at our office that people may or may not be aware of. We have a Cybex machine in our office.
We have an instrumented leg press that we can compare side to side and get some data from.
And honestly, there's a lot more data on the Cybex that we could get that I
don't know that we really utilize that we could if we wanted to,
as well as hop and landing tests, which I know people do some things like Y-balance
(05:23):
tests, like hop and landing tests, things like that.
I don't think a lot of physical therapy offices have the strength testing machines
that at their disposal like we do. So that is a unique thing that we have.
I also don't know that a lot of places do KTs, utilize the KT-2000 to actually
put a number with the objective feel of what we think the stability is like
(05:45):
by the Lachman test, by the pivot shift, et cetera.
So talk a little bit about that, the role that testing plays,
and why we believe that's a specific advantage in evaluating these athletes,
especially early on in the process, when I think a lot of times people may think,
Why do we need to check their strength at this early time point?
They're not going to have full strength. They're not even really going to be
(06:05):
that close. Why do we need to have those testing things at our disposal?
And what are we going to actually do with those measurements?
Well, I think the objective testing is really the backbone of our clinical decision making.
And I think when it boils down to it, that's really what you want to have in
your back pocket is you want to have the reasons why you make certain decisions.
And when it comes to things like return to sport, we really lean on these objective
(06:27):
numbers, which is, as you had mentioned, the testing capabilities that we have.
And we're able to pinpoint really how these athletes are doing objectively based
on, and we look at it from a variety of different ways.
Like you said, with something as simple as what people may think of as an isokinetic
test, you know, there's many more things than we use it for.
And we measure patients and we do peak torque.
(06:51):
We do give them six tries, but we end up taking the peak torque.
I know you can take an average torque of those six or whatnot.
And we usually look at that in the 60 degree per second or the 180 degree per second speed.
And then with that, we can look at it, like I said, a variety of ways,
whether looking at it as a limb symmetry index compared to pre-op normal or
normalized to body body weight.
And as you had mentioned, you know, a lot of people are looking into the rate
(07:13):
of force development and things of those nature or things of that nature, which we just haven't.
Haven't done yet necessarily. But as far as the importance of it,
it goes back to that clinical decision-making.
And we have some specific goals that we want the athletes and the patients to
hit prior to return to sport.
Things like getting back to 90% or higher with an LSN, getting back to 90% or
(07:34):
higher compared to preoperative norm. And we're able to track those over time.
And as we start getting patients back to sport, we're able to tell how they're
tolerating certain points of the the rehab.
And one thing I like to mention when I'm talking with other physical therapists,
specifically when getting these patients back to sport, is it's not necessarily
just a one-time meeting criteria or not.
(07:57):
A lot of times when you're getting athletes back, it's really a fluid continuum
because you may test them at one month and two months, and we know that they're
not going to be back to their pre-op numbers yet, but they're progressing in
the right direction. And you start having them do a little bit more.
If they're a basketball player, you're getting them on the court and doing some
individual drills, maybe when they're 80% compared to normal,
(08:17):
and then you keep bringing them back at the three-month visit and they've gone from 80 to 87.
Well, what are you going to do then? Are you going to let them go back because
they're closer to 90 or they're progressing in the right direction?
So, you know, in that scenario, we would progress them in the right direction
based on how they're tolerating it.
So, again, whether they're meeting that criteria or not, I think the early objective
measures specifically are a way to track the patient's progress.
(08:40):
And like you said, it's really the backbone of how we make our clinical decisions
for getting patients back.
This is something that I've really learned from Dr. Shelbourne in practice more
even than in my residency and fellowship is the importance of these objective
measurements that we make along the way, regardless of whether it's motion, stability,
strength in particular is an interesting one.
(09:02):
A while back, Shelbourne was kind of getting on me about starting to measure
things with regard to total knees. And I was resistant to it because I didn't
think it was going to make that much of a difference.
I thought, you know, if I make these measurements, what's it going to tell me?
And, you know, later on down the road, after making measurements that I thought
were kind of unnecessary, I thought, I started to think about,
(09:23):
well, I wonder if I can look at this.
And all of a sudden, there was the data right there. I didn't have to go measure a bunch of x-rays.
I didn't have to go say, you know, I wish I had done this. You know, it was already done.
So we think there's a lot of value in measuring parameters that may or may not.
Affect your clinical decision-making as we go along that you,
that would be useful as a, as a baseline, just because it makes you smarter.
(09:47):
It makes you more intelligent and you're thinking, you know,
you know, where are people usually at at one month and two months?
You don't really know if you don't measure it.
Secondly, I think visit over visit, it makes a big difference for our patients
to be able to see where they need to go and not, and this is,
doesn't just apply to ACL rehabilitation by itself.
It does, it matters with arthritic knee rehab and things like that as well.
(10:10):
A lot of times patients are just told, well, you need to strengthen.
Well, how much do I need to strengthen? If I strengthen, why do I need to do it now?
And how long do I need to keep doing it for the future? If they come back and
they say, well, I'm still a little sore. I still don't feel confident.
Okay, we'll continue to strengthen. Well, am I making progress or not?
If I felt like I couldn't get back to sport three months out from surgery,
(10:32):
and I still don't at four or five months out from surgery, what kind of progress am I making?
Where's my end result? And if you don't have the testing, I just don't know
how you answer that question.
So versus if you look at the strength testing at three to three month mark and
you're down by, you know, 44% or something like that, and you come back at the
four month mark, say, I don't really feel that different. I've been strengthening.
(10:53):
Well, actually, your deficit has gone from 44% to 22%. Now it's gone down significantly.
And they say, you know what, I really am making some progress,
even though I don't feel that well.
So the objective measurements can be a useful adjunct to help to motivate and
to inform our patients about where they are versus where they were and giving
(11:14):
them an idea on how they're moving forward.
So, you know, but this study, as you said, though, looking at those preoperative
factors or, excuse me, early postoperative factors to see how they lead to the
outcome really can help patients, again, I think, stay focused on here's where you are.
And we know that if we knew where that eventually led, like if you're down by
(11:35):
X amount of percentage at two months, where does that usually lead with return to sport?
I think that'd be useful for patients to know. So with that in mind,
tell me about the methods of this study and kind of the data that we looked
at to try to answer some of these questions.
So, this study was a retrospective review, and we looked at the patients in
our internal database, which I think it's important to know that all the patients
(11:56):
we were looking at were patients that had an ACL reconstruction utilizing a patellar tendon graft.
And from an exclusion standpoint, we did exclude revisions, patients that had
a bilateral procedure, a same-day bilateral, OA at the time of surgery,
or if they were missing the data that was needed for analysis.
And at the end of the exclusion criteria, we came up with 569 patients who met that criteria.
(12:19):
And again, we wanted to look at the data specifically that was measured between months one and three.
And I think everybody would agree that that is a pretty early time point in terms of ACL rehab.
And the objective measures that we were looking at were extension deficit,
strength deficit, which was measured isokinetically compared to the other side,
(12:40):
single leg hop deficit, and that was a single leg hop for distance test.
And then we also looked at the stability difference side to side,
which was measured with the KT arthrometer.
And there's really two different analyses that we did for this study.
First, we wanted to look at a mean group comparison based on being normal or
abnormal on those four objective variables.
And we've defined normal and abnormal based on the IKDC objective form.
(13:05):
So, for example, normal for extension would
be an extension deficit of less than or equal than
two degrees compared side to side and then
obviously greater than or equal to three would be abnormal and then
going down for for strength the strength deficit
as well as the single leg hop deficit we consider normal to be within 10 so
(13:25):
so less than a 10 deficit side to side on that one was considered normal and
anything outside of 10 was abnormal and then for the stability difference the
the normal category was less than or equal to three millimeters difference difference,
leaving greater than or equal to four in the admirable category.
And specifically for that analysis, we wanted to look at return to sport in
(13:45):
months and compare it between those two groups.
And then for the second analysis we wanted to look at, we wanted to take those
four early objective factors and put them into a multiple regression model and
see if there was any predictive value at that one to three month time point
as it pertained to return to sport time in months.
So once you put all that through the computer models and through the regression,
(14:08):
what did we find were the factors that led to return to sport?
So first and foremost, I mentioned that the first analysis that we did was looking
at a mean group comparison for those that were normal and abnormal as it was
categorized as I had said.
And when looking at the return to sport in months, there was a statistically
significant difference favoring those in the normal category for extension.
(14:30):
Strength, and single leg hop for distance.
For example, those that had normal extension, which was less than or equal to
two degrees compared to the other side, those patients returned to sport at
five months compared to six months for those in the abnormal category.
And again, that was statistically significantly different.
Similar with the patients that had symmetric strength within 10%,
their average time of return to sport was 4.7 months compared to 5.1 months
(14:53):
for those that were asymmetric.
And then lastly, for the hop testing, those that were normal returned at 4.6
months compared to 5.2 months for those that were asymmetric.
And the last parameter that we looked at was stability
different side to side and although the the normal group
was slightly lower than the abnormal group
that did not show to have a statistically significant difference between the
(15:14):
two and then the last analysis that we ran we did a linear regression model
that tried to that aimed to predict return to sport time in months based on
the four factors that we that were that we're talking about today as well as
a couple demographic factors.
And we found after that model that five factors lead to a faster return to sport time.
(15:35):
And those five were younger age, lower BMI, taking the graph from the contralateral
knee, having more symmetric knee extension, and more symmetric quadriceps strength.
And again, all those five factors were factors that led to a faster return to sport time.
And of those factors that were statistically significantly different,
I think it was particularly interesting to look at the magnitude of the difference.
(15:58):
If you look at the strength difference, it's about a half a month.
So we're talking about a couple of weeks worth of difference.
Same thing with single leg hop approaching a month. But when it got to extension,
extension loss outside the normal range for the IKDC criteria of two degrees
difference from the normal leg made a month difference, really made a significant
(16:19):
amount of time difference.
If you're thinking about an athlete trying to return to sport,
telling them if you can get your extension back, you can get back a month quicker
than if you can't is a significant thing.
So and even at these early parameters, I think there's often a thought that,
well, if it's not perfect now, we're going to get you keep working on it.
You're going to get there. It's OK. No, this is a this is a problem.
(16:40):
If it's not ready at a month, if your extension is not normal at a month, that's behind a lot.
And it does have a significant make a significant difference.
You know, we're crazy about extension range of motion being perfect before surgery,
making sure that you can get it in the operating room, making sure you can get
it the day of surgery and the next day after that and the one week visit at
the two week visit, get the extension perfect from the very beginning and keep
(17:04):
it way through that, keep it that way throughout the entire process.
It's not something that should come back gradually and it does make,
you know, a month difference in return to sports.
So just, just a very important, important thing. And if we look at those...
Those ones that came out of the multiple regression model that were the factors
that led to a faster return to sport.
(17:25):
Young age and lower BMI is not something the patient has really an opportunity
to change. Obviously, they can't change their age.
And in the post-surgical recovery, they can't change their BMI on that short of a notice.
But we can change as surgeons where we take the graft from.
And we believe the contralateral patella tendinograft is the best graft to be
(17:45):
used for ACL surgery. And this particular study does show some advantages from there.
And then with symmetric knee extension range of motion, symmetric quadriceps
strength, those are modifiable things that the therapist, the surgeon,
the patient, most importantly, have an opportunity to modify.
So, you know, I think that's important to keep in mind that the ones that make
(18:07):
the biggest difference are modifiable
things that we can really assist our patients in getting better.
I think you make a great point there with the modifiable versus the non-modifiable.
And that's something we've seen in our PT meeting, and everybody's really chasing
that modifiable factor of, hey, what can I as a physical therapist work on that's
going to show some meaningful change when it comes to patient outcomes?
And I think this study that we did here really at least points the people into a right direction.
(18:30):
And we talk about the clinical relevance of all these studies.
I think it's important to know that this study has the ability to really point
people in the right direction of maybe what to work on early.
And you made a good point about the magnitude of change.
And I think it should also be mentioned that we've looked in previous studies
that the inability to gain full extension does have some relationship with strength
(18:54):
training or strength results, I should say.
So the inability to have full knee extension, I would argue that it makes it
very difficult to attain full strength.
So, you know, knowing that the magnitude of change and the magnitude of strength
in the model here really showed the effect that extension loss can have on return
to sports time, I think, is an important one.
(19:14):
And that's something, especially in this early time point, to really work on
from a physical therapy standpoint.
And knowing that it's incredibly modifiable really just puts that tool in your
arsenal to really focus on in that early time.
So as we put all this together and kind of take this study and its conclusions,
(19:34):
what do you think would be the take-home points for our listeners today on what
they can learn from this study and how they could potentially change their practice?
Well, I think it's similar to what I was just speaking of in terms of what should
you work on and maybe not necessarily in the correct order, but you can make
that leap of assumption here.
And I think it's going to be important to focus on maximizing extension and
(19:58):
get it equal to the other side as quickly as possible.
And obviously that would be nice to start before surgery because I think it's
a whole lot easier to get it after surgery if you have it before surgery.
But I understand that not everybody's in a position where they're going to be
able to see these patients preoperatively.
So getting that patient back to normal extension, whether it be when you see
them at one week, two week, three week, whatever, I think that is going to be
(20:19):
the number one thing that is going to lead patients to have a better outcome.
Like I said, in previous studies we've looked at besides this one,
we have shown that the inability to gain full extension back early,
it does make it very difficult to get it back later.
And then we're talking about strength testing people for return to sport criteria
and trying to get them to pass that.
And if we're trying to expect patients to have greater than 90% from an LSI
(20:43):
standpoint or greater than 90% compared to preoperative normal at that six,
seven, eight, nine month time point when you want to start testing for return
to sport, and they're still lacking some knee extension. I think that is an uphill battle.
And obviously, hindsight's 20-20. You think, well, how could I have prevented
this? How can I get this patient stronger?
And I've been working and working and working. It's just not gaining strength.
(21:05):
It may be a motion issue where they're lacking two or three degrees of extension,
which didn't seem like a big deal early on.
But I really do think that that can have some lasting effects as it pertains
to return to sport time. Yeah, there just can't be overstated how important
that is in the early time period, and especially when you're counseling your patients pre-surgery.
In addition to rehabilitating them from the initial injury and getting them
(21:27):
ready for surgery, just getting them to understand the importance that the first
couple of weeks and first two to four weeks really needs to go perfectly for
this to be able to get a good outcome.
I'm always interested when I when I ask patients who have come for second opinions
after they've had a bad outcome or people, you know, that I see at sports physicals,
(21:47):
for example, that are still having knee issues, looking for clearance.
And you ask them, when was the first time you went to therapy after surgery?
I think it was 10 days after surgery. I went to therapy for the first time.
Wow, that's a big deal from our perspective where we don't see the patient until
the week afterwards, but we have a therapist in the facility seeing the day before they go home.
(22:10):
We have them see the next morning after surgery before they go home,
and our therapists are calling them every day to make sure things stay in the
right place for that first week.
I just can't overstate the impact of that early time period.
And getting the patients to understand that we have to make good decisions in
the first few weeks here for this to go well is really important.
You know, every once in a while you get that patient that says,
(22:31):
well, I'm having surgery, but I have this trip coming up and I want to go on
vacation with my family two weeks out of surgery or a week and a half after surgery.
Do I need to cancel it? Well, you know what?
I don't think that's a good time for you to have surgery because we know how
critically important it is for everything to go perfectly in that first month
after surgery to set us up for success.
(22:54):
And I think this study really highlights some Some of those parameters and how
getting them on board from the very beginning makes a huge difference.
And I know personally, I use that in counseling patients as they have,
if they have a graduation coming up, if they have a vacation coming up,
they have a significant life event coming up.
Maybe that's not the best time to have a surgery when you know you have something
(23:15):
significant like that going on early on, because we've shown with this study
and previous ones that if you get behind early on, it just gets really difficult
to catch up and it makes the whole process slow down.
So I try to get those patients to understand that, you know what,
I can't make you get rid of your vacation or not do this thing that's important to you.
But one, I think we should probably delay your surgery. And two,
(23:37):
if we don't, you just have to know that you're putting potentially your entire
outcome at risk and that it's really important to make good decisions in the
early time after surgery to make the whole thing go better.
Versus if we have some patients that come back in a month and they're doing
great and, you know, they sometimes are lost to follow up. And we've had patients
like that come in later on after surgery, years after surgery,
(23:59):
when we call them back for research visits or have them.
Fill out surveys that are doing fantastic and they're doing great.
And I think the reason is because they've gotten those first few weeks to go really well.
So that's my take home for our listeners on this study is to make sure that
things go well early on, educate your patients before surgery,
get them to understand that things need to go just right early on and then execute
(24:22):
that plan once surgery is done.
Well, thanks for joining us to listen to this topic tonight.
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can contact us via email at the skcpodcasts at gmail.com.
If you have any questions, like our page and follow us so you can not miss any of our content.
We have a lot of podcasts that are already in the queue waiting for you to listen
(24:43):
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So we'll see you back next time. This has been the Shell Warning Center Podcast.
Music.
Music.
(00:12):
And I'm here with Scott Bauman. And tonight we're going to be talking about
early objective predictors of return to sport time following anterior cruciate
ligament reconstruction, a topic that should be of interest to anyone interested in sports.
ACL return to play is always a hot topic, and we're going to talk about what
are some objective predictors early on in the rehabilitation process that can
give us an eye towards return to sport following ACL surgery.
(00:35):
Last week's episode was great. Dr. Fred Azar, one of my mentors from residency,
was on talking about the care of NBA athletes with knee injuries.
And that was a great conversation.
Sports Medicine Fellows, physical therapists, athletic trainers,
orthopedic surgeons, any of those groups that potentially could listen to this
podcast, go back and take a listen to Fred's episode.
(00:55):
He's a great resource and a real great resource for years of knowledge in sports
medicine and orthopedics in general.
And I think you'd learn something from that. If you'd like to find us on social
media, you can find us on our Facebook and YouTube channel at the Shelburne eCenter podcast.
You can find us on Instagram and Twitter at the SKC podcast.
(01:16):
And if you'd like to email us, you can email us at the SKC podcast at gmail.com.
So Scott, this is a study that you worked on in our office with Bill Clawson,
one of our physical therapists, along with myself and Dr.
Shelburne reviewing a lot of our ACL data to look at objective parameters.
And I think one thing that we do differently at our office that I think really
(01:36):
informs forms a lot of our decision-making is a lot of testing,
even really early, even the pre-surgery.
Phase of the patient's care, doing a lot of pre-surgical testing,
and then starting testing as early as a month, two months, three months on regular
intervals to follow where patients are doing with range of motion, with stability,
with strength, and a lot of those return-to-play criteria we're evaluating very early.
(01:59):
So with this study, we tried to look at those pretty early on and find out what
we could use as predictors.
So tell us a little bit about the background for this study and kind of how this study got started.
Sure. And like you said, we do have the unique opportunity to test these athletes
and these patients early on.
And this specifically is looking at the time of one to three months.
(02:21):
But because we have so much objective data and we have it in that early time
points, I think we are uniquely positioned to be able to look at a study of this nature.
And as far as the rationale, really a couple of different reasons.
The first of which is more internal with the treatment philosophy that we've
really been working off of for years with the Accelerated Rehabilitation program
after anterior cruciate ligament reconstruction that was really established by Dr.
(02:45):
Shelbourne in the early 90s. And the thought behind that is to really try to
work on restoring normal extension equal to the other side as quickly as possible.
And if we can get symmetric with their extension, that usually manifests itself
into normal strength a little bit quicker, and then naturally you're going to
get back to sports a little bit faster.
At least that's what we've been seeing over the years.
(03:07):
So we wanted to see, knowing that we've been working off this method of really
trying to hit the rehab early, really hit it hard pretty early by working on
those objective parameters.
We wanted to put it to the test and see, is there any predictive value in having
patients that achieve those goals early?
If they achieve them at one month versus two months versus three months versus
four months, what have you, is there going to be any differences in terms of
(03:31):
how quickly they're able to
return to sport based on those early measures that they're coming up with?
And then the second reason for the study is really just looking at the other
existing literature that's out there.
And everybody listening to this podcast that's read or done any research on
ACL reconstructions just knows
that the topic of return to sport can be controversial, first of all.
(03:53):
And second of all, it can be very, very multifactorial. I feel like most of
the studies that I look at that look on look at this topic really end with,
well, it's it's it's a multifactorial topic.
We can't for certain tell what is going to lead to return to sport.
And even further than that, are we measuring the right thing?
We go to these physical therapy meetings specifically where we're looking at
(04:15):
some of these objective tests later on as it pertains to return to sport.
And there's really a good discussion, not maybe pertaining to what the results
found. But, you know, talking with the authors of the study of,
you know, are we even measuring the correct thing? You know,
you break it down into strengthening.
Everybody agrees we need to measure strength, but how do we measure strength?
Do we measure strength with LSI?
Do we measure it compared to the other or compared to pre-op normal or normalize
(04:38):
it to body weight, what have you? So it's a pretty polarizing topic.
And I know a lot of the current literature is really towards the later stages
of rehab and how we test these athletes as it pertains to passing a criteria for return to sport.
So this is a little bit different, and we wanted to look at that early time
point to see if there's any predictive value of those measures as it pertained
(04:58):
to timing of return to sport.
Now, when it comes to testing, I think that's something that we do differently
at our office that people may or may not be aware of. We have a Cybex machine in our office.
We have an instrumented leg press that we can compare side to side and get some data from.
And honestly, there's a lot more data on the Cybex that we could get that I
don't know that we really utilize that we could if we wanted to,
as well as hop and landing tests, which I know people do some things like Y-balance
(05:23):
tests, like hop and landing tests, things like that.
I don't think a lot of physical therapy offices have the strength testing machines
that at their disposal like we do. So that is a unique thing that we have.
I also don't know that a lot of places do KTs, utilize the KT-2000 to actually
put a number with the objective feel of what we think the stability is like
(05:45):
by the Lachman test, by the pivot shift, et cetera.
So talk a little bit about that, the role that testing plays,
and why we believe that's a specific advantage in evaluating these athletes,
especially early on in the process, when I think a lot of times people may think,
Why do we need to check their strength at this early time point?
They're not going to have full strength. They're not even really going to be
(06:05):
that close. Why do we need to have those testing things at our disposal?
And what are we going to actually do with those measurements?
Well, I think the objective testing is really the backbone of our clinical decision making.
And I think when it boils down to it, that's really what you want to have in
your back pocket is you want to have the reasons why you make certain decisions.
And when it comes to things like return to sport, we really lean on these objective
(06:27):
numbers, which is, as you had mentioned, the testing capabilities that we have.
And we're able to pinpoint really how these athletes are doing objectively based
on, and we look at it from a variety of different ways.
Like you said, with something as simple as what people may think of as an isokinetic
test, you know, there's many more things than we use it for.
And we measure patients and we do peak torque.
(06:51):
We do give them six tries, but we end up taking the peak torque.
I know you can take an average torque of those six or whatnot.
And we usually look at that in the 60 degree per second or the 180 degree per second speed.
And then with that, we can look at it, like I said, a variety of ways,
whether looking at it as a limb symmetry index compared to pre-op normal or
normalized to body body weight.
And as you had mentioned, you know, a lot of people are looking into the rate
(07:13):
of force development and things of those nature or things of that nature, which we just haven't.
Haven't done yet necessarily. But as far as the importance of it,
it goes back to that clinical decision-making.
And we have some specific goals that we want the athletes and the patients to
hit prior to return to sport.
Things like getting back to 90% or higher with an LSN, getting back to 90% or
(07:34):
higher compared to preoperative norm. And we're able to track those over time.
And as we start getting patients back to sport, we're able to tell how they're
tolerating certain points of the the rehab.
And one thing I like to mention when I'm talking with other physical therapists,
specifically when getting these patients back to sport, is it's not necessarily
just a one-time meeting criteria or not.
(07:57):
A lot of times when you're getting athletes back, it's really a fluid continuum
because you may test them at one month and two months, and we know that they're
not going to be back to their pre-op numbers yet, but they're progressing in
the right direction. And you start having them do a little bit more.
If they're a basketball player, you're getting them on the court and doing some
individual drills, maybe when they're 80% compared to normal,
(08:17):
and then you keep bringing them back at the three-month visit and they've gone from 80 to 87.
Well, what are you going to do then? Are you going to let them go back because
they're closer to 90 or they're progressing in the right direction?
So, you know, in that scenario, we would progress them in the right direction
based on how they're tolerating it.
So, again, whether they're meeting that criteria or not, I think the early objective
measures specifically are a way to track the patient's progress.
(08:40):
And like you said, it's really the backbone of how we make our clinical decisions
for getting patients back.
This is something that I've really learned from Dr. Shelbourne in practice more
even than in my residency and fellowship is the importance of these objective
measurements that we make along the way, regardless of whether it's motion, stability,
strength in particular is an interesting one.
(09:02):
A while back, Shelbourne was kind of getting on me about starting to measure
things with regard to total knees. And I was resistant to it because I didn't
think it was going to make that much of a difference.
I thought, you know, if I make these measurements, what's it going to tell me?
And, you know, later on down the road, after making measurements that I thought
were kind of unnecessary, I thought, I started to think about,
(09:23):
well, I wonder if I can look at this.
And all of a sudden, there was the data right there. I didn't have to go measure a bunch of x-rays.
I didn't have to go say, you know, I wish I had done this. You know, it was already done.
So we think there's a lot of value in measuring parameters that may or may not.
Affect your clinical decision-making as we go along that you,
that would be useful as a, as a baseline, just because it makes you smarter.
(09:47):
It makes you more intelligent and you're thinking, you know,
you know, where are people usually at at one month and two months?
You don't really know if you don't measure it.
Secondly, I think visit over visit, it makes a big difference for our patients
to be able to see where they need to go and not, and this is,
doesn't just apply to ACL rehabilitation by itself.
It does, it matters with arthritic knee rehab and things like that as well.
(10:10):
A lot of times patients are just told, well, you need to strengthen.
Well, how much do I need to strengthen? If I strengthen, why do I need to do it now?
And how long do I need to keep doing it for the future? If they come back and
they say, well, I'm still a little sore. I still don't feel confident.
Okay, we'll continue to strengthen. Well, am I making progress or not?
If I felt like I couldn't get back to sport three months out from surgery,
(10:32):
and I still don't at four or five months out from surgery, what kind of progress am I making?
Where's my end result? And if you don't have the testing, I just don't know
how you answer that question.
So versus if you look at the strength testing at three to three month mark and
you're down by, you know, 44% or something like that, and you come back at the
four month mark, say, I don't really feel that different. I've been strengthening.
(10:53):
Well, actually, your deficit has gone from 44% to 22%. Now it's gone down significantly.
And they say, you know what, I really am making some progress,
even though I don't feel that well.
So the objective measurements can be a useful adjunct to help to motivate and
to inform our patients about where they are versus where they were and giving
(11:14):
them an idea on how they're moving forward.
So, you know, but this study, as you said, though, looking at those preoperative
factors or, excuse me, early postoperative factors to see how they lead to the
outcome really can help patients, again, I think, stay focused on here's where you are.
And we know that if we knew where that eventually led, like if you're down by
(11:35):
X amount of percentage at two months, where does that usually lead with return to sport?
I think that'd be useful for patients to know. So with that in mind,
tell me about the methods of this study and kind of the data that we looked
at to try to answer some of these questions.
So, this study was a retrospective review, and we looked at the patients in
our internal database, which I think it's important to know that all the patients
(11:56):
we were looking at were patients that had an ACL reconstruction utilizing a patellar tendon graft.
And from an exclusion standpoint, we did exclude revisions, patients that had
a bilateral procedure, a same-day bilateral, OA at the time of surgery,
or if they were missing the data that was needed for analysis.
And at the end of the exclusion criteria, we came up with 569 patients who met that criteria.
(12:19):
And again, we wanted to look at the data specifically that was measured between months one and three.
And I think everybody would agree that that is a pretty early time point in terms of ACL rehab.
And the objective measures that we were looking at were extension deficit,
strength deficit, which was measured isokinetically compared to the other side,
(12:40):
single leg hop deficit, and that was a single leg hop for distance test.
And then we also looked at the stability difference side to side,
which was measured with the KT arthrometer.
And there's really two different analyses that we did for this study.
First, we wanted to look at a mean group comparison based on being normal or
abnormal on those four objective variables.
And we've defined normal and abnormal based on the IKDC objective form.
(13:05):
So, for example, normal for extension would
be an extension deficit of less than or equal than
two degrees compared side to side and then
obviously greater than or equal to three would be abnormal and then
going down for for strength the strength deficit
as well as the single leg hop deficit we consider normal to be within 10 so
(13:25):
so less than a 10 deficit side to side on that one was considered normal and
anything outside of 10 was abnormal and then for the stability difference the
the normal category was less than or equal to three millimeters difference difference,
leaving greater than or equal to four in the admirable category.
And specifically for that analysis, we wanted to look at return to sport in
(13:45):
months and compare it between those two groups.
And then for the second analysis we wanted to look at, we wanted to take those
four early objective factors and put them into a multiple regression model and
see if there was any predictive value at that one to three month time point
as it pertained to return to sport time in months.
So once you put all that through the computer models and through the regression,
(14:08):
what did we find were the factors that led to return to sport?
So first and foremost, I mentioned that the first analysis that we did was looking
at a mean group comparison for those that were normal and abnormal as it was
categorized as I had said.
And when looking at the return to sport in months, there was a statistically
significant difference favoring those in the normal category for extension.
(14:30):
Strength, and single leg hop for distance.
For example, those that had normal extension, which was less than or equal to
two degrees compared to the other side, those patients returned to sport at
five months compared to six months for those in the abnormal category.
And again, that was statistically significantly different.
Similar with the patients that had symmetric strength within 10%,
their average time of return to sport was 4.7 months compared to 5.1 months
(14:53):
for those that were asymmetric.
And then lastly, for the hop testing, those that were normal returned at 4.6
months compared to 5.2 months for those that were asymmetric.
And the last parameter that we looked at was stability
different side to side and although the the normal group
was slightly lower than the abnormal group
that did not show to have a statistically significant difference between the
(15:14):
two and then the last analysis that we ran we did a linear regression model
that tried to that aimed to predict return to sport time in months based on
the four factors that we that were that we're talking about today as well as
a couple demographic factors.
And we found after that model that five factors lead to a faster return to sport time.
(15:35):
And those five were younger age, lower BMI, taking the graph from the contralateral
knee, having more symmetric knee extension, and more symmetric quadriceps strength.
And again, all those five factors were factors that led to a faster return to sport time.
And of those factors that were statistically significantly different,
I think it was particularly interesting to look at the magnitude of the difference.
(15:58):
If you look at the strength difference, it's about a half a month.
So we're talking about a couple of weeks worth of difference.
Same thing with single leg hop approaching a month. But when it got to extension,
extension loss outside the normal range for the IKDC criteria of two degrees
difference from the normal leg made a month difference, really made a significant
(16:19):
amount of time difference.
If you're thinking about an athlete trying to return to sport,
telling them if you can get your extension back, you can get back a month quicker
than if you can't is a significant thing.
So and even at these early parameters, I think there's often a thought that,
well, if it's not perfect now, we're going to get you keep working on it.
You're going to get there. It's OK. No, this is a this is a problem.
(16:40):
If it's not ready at a month, if your extension is not normal at a month, that's behind a lot.
And it does have a significant make a significant difference.
You know, we're crazy about extension range of motion being perfect before surgery,
making sure that you can get it in the operating room, making sure you can get
it the day of surgery and the next day after that and the one week visit at
the two week visit, get the extension perfect from the very beginning and keep
(17:04):
it way through that, keep it that way throughout the entire process.
It's not something that should come back gradually and it does make,
you know, a month difference in return to sports.
So just, just a very important, important thing. And if we look at those...
Those ones that came out of the multiple regression model that were the factors
that led to a faster return to sport.
(17:25):
Young age and lower BMI is not something the patient has really an opportunity
to change. Obviously, they can't change their age.
And in the post-surgical recovery, they can't change their BMI on that short of a notice.
But we can change as surgeons where we take the graft from.
And we believe the contralateral patella tendinograft is the best graft to be
(17:45):
used for ACL surgery. And this particular study does show some advantages from there.
And then with symmetric knee extension range of motion, symmetric quadriceps
strength, those are modifiable things that the therapist, the surgeon,
the patient, most importantly, have an opportunity to modify.
So, you know, I think that's important to keep in mind that the ones that make
(18:07):
the biggest difference are modifiable
things that we can really assist our patients in getting better.
I think you make a great point there with the modifiable versus the non-modifiable.
And that's something we've seen in our PT meeting, and everybody's really chasing
that modifiable factor of, hey, what can I as a physical therapist work on that's
going to show some meaningful change when it comes to patient outcomes?
And I think this study that we did here really at least points the people into a right direction.
(18:30):
And we talk about the clinical relevance of all these studies.
I think it's important to know that this study has the ability to really point
people in the right direction of maybe what to work on early.
And you made a good point about the magnitude of change.
And I think it should also be mentioned that we've looked in previous studies
that the inability to gain full extension does have some relationship with strength
(18:54):
training or strength results, I should say.
So the inability to have full knee extension, I would argue that it makes it
very difficult to attain full strength.
So, you know, knowing that the magnitude of change and the magnitude of strength
in the model here really showed the effect that extension loss can have on return
to sports time, I think, is an important one.
(19:14):
And that's something, especially in this early time point, to really work on
from a physical therapy standpoint.
And knowing that it's incredibly modifiable really just puts that tool in your
arsenal to really focus on in that early time.
So as we put all this together and kind of take this study and its conclusions,
(19:34):
what do you think would be the take-home points for our listeners today on what
they can learn from this study and how they could potentially change their practice?
Well, I think it's similar to what I was just speaking of in terms of what should
you work on and maybe not necessarily in the correct order, but you can make
that leap of assumption here.
And I think it's going to be important to focus on maximizing extension and
(19:58):
get it equal to the other side as quickly as possible.
And obviously that would be nice to start before surgery because I think it's
a whole lot easier to get it after surgery if you have it before surgery.
But I understand that not everybody's in a position where they're going to be
able to see these patients preoperatively.
So getting that patient back to normal extension, whether it be when you see
them at one week, two week, three week, whatever, I think that is going to be
(20:19):
the number one thing that is going to lead patients to have a better outcome.
Like I said, in previous studies we've looked at besides this one,
we have shown that the inability to gain full extension back early,
it does make it very difficult to get it back later.
And then we're talking about strength testing people for return to sport criteria
and trying to get them to pass that.
And if we're trying to expect patients to have greater than 90% from an LSI
(20:43):
standpoint or greater than 90% compared to preoperative normal at that six,
seven, eight, nine month time point when you want to start testing for return
to sport, and they're still lacking some knee extension. I think that is an uphill battle.
And obviously, hindsight's 20-20. You think, well, how could I have prevented
this? How can I get this patient stronger?
And I've been working and working and working. It's just not gaining strength.
(21:05):
It may be a motion issue where they're lacking two or three degrees of extension,
which didn't seem like a big deal early on.
But I really do think that that can have some lasting effects as it pertains
to return to sport time. Yeah, there just can't be overstated how important
that is in the early time period, and especially when you're counseling your patients pre-surgery.
In addition to rehabilitating them from the initial injury and getting them
(21:27):
ready for surgery, just getting them to understand the importance that the first
couple of weeks and first two to four weeks really needs to go perfectly for
this to be able to get a good outcome.
I'm always interested when I when I ask patients who have come for second opinions
after they've had a bad outcome or people, you know, that I see at sports physicals,
(21:47):
for example, that are still having knee issues, looking for clearance.
And you ask them, when was the first time you went to therapy after surgery?
I think it was 10 days after surgery. I went to therapy for the first time.
Wow, that's a big deal from our perspective where we don't see the patient until
the week afterwards, but we have a therapist in the facility seeing the day before they go home.
(22:10):
We have them see the next morning after surgery before they go home,
and our therapists are calling them every day to make sure things stay in the
right place for that first week.
I just can't overstate the impact of that early time period.
And getting the patients to understand that we have to make good decisions in
the first few weeks here for this to go well is really important.
You know, every once in a while you get that patient that says,
(22:31):
well, I'm having surgery, but I have this trip coming up and I want to go on
vacation with my family two weeks out of surgery or a week and a half after surgery.
Do I need to cancel it? Well, you know what?
I don't think that's a good time for you to have surgery because we know how
critically important it is for everything to go perfectly in that first month
after surgery to set us up for success.
(22:54):
And I think this study really highlights some Some of those parameters and how
getting them on board from the very beginning makes a huge difference.
And I know personally, I use that in counseling patients as they have,
if they have a graduation coming up, if they have a vacation coming up,
they have a significant life event coming up.
Maybe that's not the best time to have a surgery when you know you have something
(23:15):
significant like that going on early on, because we've shown with this study
and previous ones that if you get behind early on, it just gets really difficult
to catch up and it makes the whole process slow down.
So I try to get those patients to understand that, you know what,
I can't make you get rid of your vacation or not do this thing that's important to you.
But one, I think we should probably delay your surgery. And two,
(23:37):
if we don't, you just have to know that you're putting potentially your entire
outcome at risk and that it's really important to make good decisions in the
early time after surgery to make the whole thing go better.
Versus if we have some patients that come back in a month and they're doing
great and, you know, they sometimes are lost to follow up. And we've had patients
like that come in later on after surgery, years after surgery,
(23:59):
when we call them back for research visits or have them.
Fill out surveys that are doing fantastic and they're doing great.
And I think the reason is because they've gotten those first few weeks to go really well.
So that's my take home for our listeners on this study is to make sure that
things go well early on, educate your patients before surgery,
get them to understand that things need to go just right early on and then execute
(24:22):
that plan once surgery is done.
Well, thanks for joining us to listen to this topic tonight.
Again, as we talked about beforehand, you can find us on social media or you
can contact us via email at the skcpodcasts at gmail.com.
If you have any questions, like our page and follow us so you can not miss any of our content.
We have a lot of podcasts that are already in the queue waiting for you to listen
(24:43):
to and some really interesting topics that you can learn a lot from.
If you like what you've heard, leave us a five-star review and a comment so
people that come behind can see what your thoughts were as well and hopefully enjoy the podcast.
So we'll see you back next time. This has been the Shell Warning Center Podcast.
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