RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Goes, Rodrigo A.; Cossich, Victor R. A.; França, Bráulio R.; Campos, André Siqueira; Souza, Gabriel Garcez A.; Bastos, Ricardo do Carmo; Grangeiro Neto, João A.

doi:10.1590/1517-8692202026062019_0056

Rodrigo A. Goes Correspondence: Rodrigo Araujo Goes, Divisão de Traumatologia e Ortopedia (DITRO). Avenida Brasil, 500, 2° andar, Caju, Rio de Janeiro, RJ, Brazil. 20940-070. rodrigogoes4@yahoo.com.br

Orthopedic Physician

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Center for Specialized Care in Sports Trauma, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0002-1209-4425

Victor R. A. Cossich

Physical Education Professional

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Research Division, Neuromuscular Research Laboratory, Rio de Janeiro, RJ, Brazil.

Universidade Federal do Rio de Janeiro, School of Physical Education and Sport (UFRJ-EEFD), Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0002-3984-6121

Bráulio R. França

Physiotherapist

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Center for Specialized Care in Sports Trauma, Rio de Janeiro, RJ, Brazil.

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Physiotherapy Department, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0002-2836-2033

André Siqueira Campos

Orthopedic Physician

Hospital Federal dos Servidores do Estado do Rio de Janeiro, Knee Group, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0002-9400-4023

Gabriel Garcez A. Souza

Orthopedic Physician

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Center for Specialized Care in Sports Trauma, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0002-1732-1092

Ricardo do Carmo Bastos

Orthopedic Physician

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Center for Specialized Care in Sports Trauma, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0001-6571-4512

João A. Grangeiro Neto

Orthopedic Physician

Instituto Nacional de Traumatologia e Ortopedia Jammil Haddad (INTO), Center for Specialized Care in Sports Trauma, Rio de Janeiro, RJ, Brazil.

https://orcid.org/0000-0001-6532-4362

Correspondence: Rodrigo Araujo Goes, Divisão de Traumatologia e Ortopedia (DITRO). Avenida Brasil, 500, 2° andar, Caju, Rio de Janeiro, RJ, Brazil. 20940-070. rodrigogoes4@yahoo.com.br

All authors declare no potential conflict of interest related to this article

AUTHORS' CONTRIBUTIONS: Each author made significant individual contributions to this manuscript. RG and VC: outlined the themes and subthemes. RG, VC, BF and JN: general review and final approval of the manuscript. VC: writing the functional evaluation topics, preparation of the images. BF: writing topics related to physiotherapy and functional evaluation, elaboration of the tables. RG, AC, GS, RB and JN were responsible for writing the medical and surgical topics.

Test	ACL - RSI (Previous Cruciate Ligament - Return to Sport after Injury)	QASLS (Quality Assessment of Single-Leg Loading)	Hop tests	MICODT (Modified Illinois Change of Direction Test)
Description	Psychological readiness questionnaire	Qualitative analysis of the motor strategy of body segments during single-leg loading.	Physical screening including hop tests (single, triple, side, crossover)	Speed test and direction change
Original Score	%	0 to 10	Symmetry between limbs (%)	Time
K-START score (Knee Santy Athletic Return to Sport)	0 to 3 points	0 to 3 points	0 to 12 points (4 tests)	0 to 3 points
K-START score (Knee Santy Athletic Return to Sport)	0: <55% 1:≥ 55% and <63% 2:≥ 63% and <76% 3:≥ 76%	0: 3 ≥ in the QASLS 1: 2 in the QASLS 2: 1 in the QASLS 0: 3 in the QASLS Extra penalty: -3 points in case of dynamic valgus.	0: pain prevents performance 1:≤ 80% 2:> 80% and 90%≤ 3: ≥ 90%	0: pain prevents performance 1:> 13.5s> 2:> 12 and ≤13.5s 3: ≤ 12.5s

Objectives	Activities	Devices	Progression
Phase 0: pre-operatory
Full ROM MS preserved	Weight Training ROM exercises	In physiotherapy At the gym At home	Isokinetic 60 °/s EXT and FLEX ^* * performed for later comparisons in the post-ACLR. (PT, FLEX / EXT, LSI) RTD EXT ^* * performed for later comparisons in the post-ACLR. (initial and late, LSI) Single Hop test^* * performed for later comparisons in the post-ACLR. (LSI) IKDC ^* * performed for later comparisons in the post-ACLR. Lysholm ^* * performed for later comparisons in the post-ACLR. ACLR
Phase 1: immediate post-surgery (d1 to d10)
Swelling reduction ROM 0° to 90° Muscle activation and quadriceps motor control Safe walking (with 2 crutches)	Cryotherapy (>3x/day) Patellar mobilization ROM exercises Quadriceps isometric exercises LSR Weight shift exercises NMES	At home 2 crutches (WBAT) Extension brace (withdraw for ROM gain)	10 Postoperative days LSR (3 active reps)
Phase 2: initial rehabilitation (d10 to w3)
Swelling reduction ROM 0° to 110° Quadriceps motor control Quadriceps muscle strength Safe walking (with 1 crutch)	Cryotherapy (>3x/day) Patellar mobilization ROM exercises LSR (in 3 directions) ^* * started only if the progression criteria of the previous phase are met. Knee extension (no load) Weight shift exercises Mini squats (45°)^* * started only if the progression criteria of the previous phase are met. NMES	At home 1 crutch (WBAT) ^* * started only if the progression criteria of the previous phase are met. Extension brace (risky situations) ^* * started only if the progression criteria of the previous phase are met.	3 weeks post-ACLR Adequate gait pattern with 1 crutch without immobilizer Withdrawal of stitches
Phase 3: strengthening and neuromotor control (w3 to w6)
Swelling resolution ROM> 85% of CL limb OL motor control OL MS gain Walking without crutches	ROM exercises LSR (in 3 directions)^* * started only if the progression criteria of the previous phase are met. Knee extension (no load) Strengthening of calf, adductors and hip abductors Weight shift exercises Mini squats (45°) Standing knee flexion Pool walks^* * started only if the progression criteria of the previous phase are met. Initial sensorimotor control	In physiotherapy Articulated brace (risky situations)	6 weeks post-ACLR Adequate walking pattern without crutches Full ROM or> 85% CL Improved muscle trophism
Phase 4: advanced rehabilitation (w6 to w12)
OL MS gain Improvement of sensorimotor and neuromuscular functions Gain of confidence in the operated limb	Mini squats (60°) Knee extension ankle weights Knee flexion ankle weights Strengthening of calf, adductors and hip abductors Pool jogging Progress sensorimotor control Stacionary bicycle (W8) Treadmill (up to 5km/h) ^* * started only if the progression criteria of the previous phase are met.	In physiotherapy	12 weeks post-ACLR Single-leg squat (clean or almost clean) Good gait pattern on the treadmill Good muscle trophism
Phase 5: return to activity (w12 to w24)
Complete restoration of MS from OL Beginning of non-competitive sporting gestures (without turns)	Free OKC and CKC weight training machines Advanced sensorimotor control Start running on the treadmill (W16) ^* * started only if the progression criteria of the previous phase are met. Non-competitive gesture (W18) ^* * started only if the progression criteria of the previous phase are met.	In physiotherapy At the gym	24 weeks post-ACLR Isokinetic 60 °/s EXT and FLEX^# # realized in the post-ACLR at 24 weeks and repeats every subsequent month until the total release for Return to Sport, release needs to reach LSI ≥ 90%, specifically for FLEX/EXT value between 60-80%. (PT, FLEX/EXT, LSI) RTD EXT^# # realized in the post-ACLR at 24 weeks and repeats every subsequent month until the total release for Return to Sport, release needs to reach LSI ≥ 90%, specifically for FLEX/EXT value between 60-80%. (early and late, LSI) Single Hop test^# # realized in the post-ACLR at 24 weeks and repeats every subsequent month until the total release for Return to Sport, release needs to reach LSI ≥ 90%, specifically for FLEX/EXT value between 60-80%. (LSI) IKDC^# # realized in the post-ACLR at 24 weeks and repeats every subsequent month until the total release for Return to Sport, release needs to reach LSI ≥ 90%, specifically for FLEX/EXT value between 60-80%. Lysholm^# # realized in the post-ACLR at 24 weeks and repeats every subsequent month until the total release for Return to Sport, release needs to reach LSI ≥ 90%, specifically for FLEX/EXT value between 60-80%. Running on the treadmill
Phase 6: transition to sport (w24 or more)
Improve confidence to return to play Adequate reaction to sport-specific tasks Explosive MS gain Gradual return to sports activity	Maintenance of physical training - Emphasis on explosive strength Plyometrics^* * started only if the progression criteria of the previous phase are met. Changes in direction and turn^* * started only if the progression criteria of the previous phase are met. Progressing sports gestures^* * started only if the progression criteria of the previous phase are met.	At the gym In “field”	Optimal movement pattern for specific pre-programmed tasks Athlete confidence

[1] Correspondence: Rodrigo Araujo Goes, Divisão de Traumatologia e Ortopedia (DITRO). Avenida Brasil, 500, 2° andar, Caju, Rio de Janeiro, RJ, Brazil. 20940-070. rodrigogoes4@yahoo.com.br

Brasil

Brasil

RETURN TO PLAY AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

RETORNO AO ESPORTE APÓS A RECONSTRUÇÃO DO LIGAMENTO CRUZADO ANTERIOR

RETORNO AL DEPORTE DESPUÉS DE RECONSTRUCCIÓN DEL LIGAMENTO CRUZADO ANTERIOR

ABSTRACT