Deciding when you can return to competitive sport after an ACL reconstruction depends on two things: whether the new graft has matured enough, and whether your strength, balance and control have returned to near-normal levels.
Return to play testing, carried out by a trained physiotherapist, checks the second of these. Passing the tests has been linked to a lower risk of re-injuring the graft, so the right time to return is when you are physically ready, which may be 12 months or later. [5]
At a Glance
- An ACL graft goes through a remodelling process, called ligamentisation, and much of this happens in the first 12 months.
- Returning to sport before the graft has matured exposes it to high loads while it is still weak.
- Return to play testing checks strength, hopping, jumping, agility and confidence.
- In one study, people who did not meet return-to-sport criteria had about four times the risk of graft rupture.
- If you do not pass, keep working on your rehabilitation and repeat the tests later.
Why shouldn’t you return to sport before about 1 year?
Surgeons use guidelines based on how grafts heal to set the minimum time before returning to sport. After an ACL reconstruction, the body breaks down the cells in the new graft and rebuilds it. This process is called ligamentisation. [1]
Ligamentisation can take years to complete, but much of the remodelling happens within 12 months. Returning to play before the graft has matured exposes it to high loads while it is still weak, which carries a significant risk of tearing it.
What is return to play testing?
The risk of re-rupturing the graft remains higher than normal between one and two years after an ACL reconstruction. It is therefore important that you are physically prepared before you return to play. Return to play testing, carried out by an appropriately trained physiotherapist, looks at muscle bulk and strength, balance and coordination.
Tests may include:
- the ACL Return to Sport after Injury (ACL-RSI) scale, which measures confidence
- single-leg hop for distance
- single-leg triple hop for distance
- single-leg triple crossover hop for distance
- box drop vertical jump
- a modified agility T-test
- a four-repetition maximum on the 45-degree incline leg press.
If you pass, you can begin a graduated return to competitive sport. This is also the time to start ACL injury prevention exercises, which need to be done before every training session and match to be effective. [2] [3] [4]
What if you fail the return to play test?
If you do not pass, you should not return to sport yet. Your physiotherapist will explain which areas need more work, and the test can be repeated once you have improved. Supervised rehabilitation is important.
Many people do not pass the first time. Common reasons include not having supervised rehabilitation, not completing the rehabilitation program, or being unsure of your own physical readiness.
Does return to play testing work?
The evidence suggests it helps. In one study, athletes who did not meet six clinical discharge criteria before returning to sport had about four times the risk of ACL graft rupture compared with those who did. [5] This is why Dr Vishal Pai recommends that all patients complete return to play testing at the end of their rehabilitation.
An ACL reconstruction is a long-term investment. The operation is only one part of the treatment, and completing the rehabilitation is just as important.
Summary
A return to play test assesses your physical readiness for sport after an ACL reconstruction, and passing it has been linked to a lower risk of graft re-rupture. You should return to play when you are physically ready, which may be at 12 months, 18 months or later depending on your progress.
If you would like to discuss how this applies to your knee, you can book a consultation with Dr Vishal Pai.
References
Show all 5 referencesHide references
- Pauzenberger L et al. 2013. “Ligamentization” in hamstring tendon grafts after anterior cruciate ligament reconstruction: a systematic review of the literature and a glimpse into the future. Arthroscopy.
- Sadoghi P et al. 2012. Effectiveness of anterior cruciate ligament injury prevention training programs. The Journal of Bone and Joint Surgery (American).
- Myer GD et al. 2004. Rationale and clinical techniques for anterior cruciate ligament injury prevention among female athletes. Journal of Athletic Training.
- Silvers-Granelli HJ et al. 2017. Does the FIFA 11+ injury prevention program reduce the incidence of ACL injury in male soccer players?. Clinical Orthopaedics and Related Research.
- Kyritsis P et al. 2016. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. British Journal of Sports Medicine.
Planning your return to sport after ACL surgery?
Dr Vishal Pai performs ACL reconstruction and works with physiotherapists on return to play testing. You can arrange a consultation to discuss realistic expectations for your return to sport.
Written by Dr Vishal Pai
Vishal is an experienced knee surgeon based in Bayside, Melbourne. He consults at Sandringham Orthopaedic Specialists and operates at The Avenue Hospital and Calvary Holmesglen Private Hospital. His practice focuses on sports knee surgery, including ACL reconstruction and meniscal repair, as well as robotic knee replacement.