Post-Surgical Return to Sport Criteria

Andrew Barnes, SPT

And How to Get Patients There

When talking about an athlete, what is function?

What is the goal of a functional test?

Overview

• Upper Extremity
• Criteria
• Phases
• Rehab Ideas
• Lower Extremity
• Criteria
• Strength Training
• Plyometric Training
• Returning to Running
• Final Thoughts
• Questions

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The Upper Extremity

Current RTS Rates^1,2

• Isolated Arthroscopic SLAP Repair
• ~80% returned to sport
• ~80% of those who returned to sport did so at pre-injury levels
• Mean age – 31 years
• Arthroscopic SLAP Repair with Rotator Cuff Debridement
• ~77% returned to sport
• ~87% of those who returned to sport did so at pre-injury levels
• Mean age – 22 years
• Biceps Tenodesis [for SLAP tear]
• ~85% returned to sport
• ~93% of those who returned to sport did so at pre-injury levels
• Mean age – 42 years
• Rotator Cuff Repair
• ~85% returned to sport
• ~78% of those who returned to sport did so at pre-injury levels (~63% of professional and competitive athletes)
• Mean age – 43 years (range 15-81 years)

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RTS Criteria^3,4

• WOSI >95
• Full PROM, painfree & no apprehension
• Isokinetic strength @ 180°/sec
• ER/IR ratio – .72-.76
• ER strength – 95-100% limb symmetry index (LSI)
• IR strength – 100-110% LSI
• Unilateral pushing and pulling >100% LSI
• Prone Ball Drop
• Closed Kinetic Chain Upper Extremity Stability Test

Phases of Rehabilitation⁴

• Phase I – decrease pain and inflammation, restore ROM
• Anticipate a large difference in ER/IR in dominant vs. non-dominant
• Due to (chronic) osseous changes and/or acute load – goal = 180° of total motion, not 90° ER/ 90° IR
• Professional baseball players – averaged 132° ER and 51° IR on throwing side
• Phase II – strengthen, improve flexibility, ROM, enhance NM control
• Typical shoulder/periscapular strengthening, begin incorporating core, trunk
• Phase III – Maintain full ROM, strengthen, begin return to activity
• Interval throwing program (ITP), advanced stabilization exercises, shoulder endurance exercises
• Phase IV – Progress ITP, continue strength and flexibility, return to throwing

Phase III and IV Ideas

• Shoulder proprioceptive/ NM Control/ Strength - Body blade drills, rhythmic stabilizations (with weighted ball/ band/ cable), kettlebell carries, prone ball drop activities, plyometric drills
• Thoracic mobility - quadruped rotation, cat/cow
• Moving away from the shoulder – plank variation, core stabilization, full body shoulder movements, pushups

The Lower Extremity (ACL focused)

Post-Operative ACL Phases of Rehabilitation⁵

• 3 phases
• Acute Phase
• Eliminate effusion
• Regain ROM
• Minimize muscle atrophy (i.e. NMES, quad sets throughout the day)
• Rehabilitation Phase
• Regain neuromuscular control of terminal knee extension in weight-bearing positions
• >/= 80% muscle strength and hop performance (begin hops at 12 weeks)
• Return To Sport Phase
• >90% muscle strength and hop performance
• Transition through sport specific drills and gradual participation

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RTS Criteria^5,6

• >90% Symmetry on the Following:
• Quadriceps strength
• Single Leg Hop for Distance
• Crossover Hop for Distance
• Triple Hop for Distance
• 6m Timed Hop
• Patient Reported Outcome Measures
• Knee Outcome Survey – ADL Scale
• Global Rating Scale of Perceived Function

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Grindem et al 2016 Results⁵

• 100 total participants completed the survey, 83 of which played a ”level 1” sport (running/cutting/jumping)
• Passing RTS Criteria was associated with an 84% decreased re-injury rate
• 38.2% who failed RTS Criteria suffered a re-injury
• 5.6% who passed RTS Criteria suffered a re-injury
• Each one-month delay of RTS (up to nine months), was associated with a 51% decrease in reinjury rate
• 39.5% who returned to a level 1 sport prior to nine months suffered an injury
• 19.4% who returned to a level 1 sport after nine months suffered an injury

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Performing the Tests⁵

• Quadricep Strength
• Gold standard - isokinetic strength @ 60°/sec
• HHD, braced by a hard stop (e.g. gait belt) is adequate
• 4 Submax trials - 1 minute rest – 5 max effort repetitions
• Hop Tests
• One practice trial
• Two real trials
• Uninvolved always tested first
• Videos
• Perform Outcome Measures after Hop Tests

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Attaining the RTS Criteria^7,8

• Strength (mid-late stages)
• Consider strength and conditioning principles
• Utilize RPE, %1RM, repetitions in reserve
• Frequency/Set/Reps/Rest
• Progression – 2 by 2 rule, RPE⁷, Acute-Chronic Workload ratio⁸
• Single leg strengthening
• Sport-specific strengthening in later stages
• ex. rotational movements in baseball players
• Don’t forget isolated strengthen - especially the quads!
• Hypertrophy 🡪 Power / Endurance (?)

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Attaining the RTS Criteria^9,10,11

• Plyometrics
• Start with basics, then move sport specific -> best carryover to their sport
• Don’t forget – plyometrics and about power and neuromuscular control
• Adequate rest - ~5-10s between reps and 2-3 minutes between sets
• Measure in foot contacts
• For any neuromuscular gains you need quality repetitions and a lot of them
• Consider acute-chronic workload for increasing demand
• Don’t perform while taxed – preferably at the beginning of the session following warm-up
• Also consider super-setting with lighter exercise or stretch

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Attaining the RTS Criteria⁹

• 4-stage plyometric progression
• Guidelines to Begin – Stage 1
• 0-2 pain on Numeric Rating Scale and no swelling with other tasks
• Full knee extension, >120° knee flexion
• <20% asymmetry in loaded squat
• Isometric knee extensor strength LSI >70%
• Stage 1 (10-14 weeks)
• 50 foot contacts
• Movements with long ground contact times (1-2s) = Decreased GRFs
• BL offset (ex. alternating box jumps), BL asymmetrical (Lunge push back), sub-maximal BL symmetrical (countermovement jump to box)
• Continue strengthening with progression to single leg, introduce treadmill running

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Return to Running^12,13

• Can begin at ~8 weeks
• Some hold off until ~12 weeks
• 8 weeks – early RTS? 12 weeks – standard?
• If – quadricep symmetry >/=80%, effusion of trace or less, demonstrate understanding of the soreness rule
• Also - <2 VAS, 95% flexion ROM, 0° extension ROM
• Progressions as outlined

Thoughts

• We have limitations in PT – insurance, billing, space, etc…
• There are no perfect exercises or perfect exercise progressions
• The best exercises/tasks to choose may be the ones you can cue the best
• The only certainties are progressive overload, motor learning principles , and specificity
• They may not pass RTS with us at four months, six months, discharge…
• Need to build the base to set them up for success moving forward
• Including finding the right provider to continue (if the patient has the means)
• Best functional testing = progressive return to sport?

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References

1. Abdul-Rassoul H, Defazio M, Curry EJ, Galvin JW, Li X. Return to Sport After the Surgical Treatment of Superior Labrum Anterior to Posterior Tears: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2019;7(5):232596711984189. doi:10.1177/2325967119841892

2. Klouche S, Lefevre N, Herman S, Gerometta A, Bohu Y. Return to Sport After Rotator Cuff Tear Repair: A Systematic Review and Meta-analysis. Am J Sports Med. 2016;44(7):1877-1887. doi:10.1177/0363546515598995

3. Wilk KE, Williams RA, Dugas JR, Cain EL, Andrews JR. Current Concepts in the Assessment and Rehabilitation of the Thrower’s Shoulder. Operative Techniques in Sports Medicine. 2016;24(3):170-180. doi:10.1053/j.otsm.2016.04.004

4. Kirkley A, Griffin S, McLintock H, Ng L. The Development and Evaluation of a Disease-Specific Quality of Life Measurement Tool for Shoulder Instability. Am J Sports Med. 1998;26(6):764-772. doi:10.1177/03635465980260060501

5. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med. 2016;50(13):804-808. doi:10.1136/bjsports-2016-096031

6. Logerstedt D, Di Stasi S, Grindem H, et al. Self-Reported Knee Function Can Identify Athletes Who Fail Return-to-Activity Criteria up to 1 Year After Anterior Cruciate Ligament Reconstruction: A Delaware-Oslo ACL Cohort Study. J Orthop Sports Phys Ther. 2014;44(12):914-923. doi:10.2519/jospt.2014.4852

7. Day ML, Mcguigan MR, Brice G, Foster C. Monitoring exercise intensity during resistance training using the session RPE scale. J Str Conditon Res. 2004; 18(2):353–358.

8. Blanch P, Gabbett TJ. Has the athlete trained enough to return to play safely? The acute:chronic workload ratio permits clinicians to quantify a player’s risk of subsequent injury. Br J Sports Med. 2016;50(8):471-475. doi:10.1136/bjsports-2015-095445

9. Buckthorpe M, Della Villa F. Recommendations for Plyometric Training after ACL Reconstruction – A Clinical Commentary. International Journal of Sports Physical Therapy. Published online June 1, 2021. doi:10.26603/001c.23549

10. National Strength and Conditioning Association. Position statement: Explosive/plyometric exercises. NSCA J 15:16, 1993.

11. Wolpert DM, Diedrichsen J, Flanagan JR. Principles of sensorimotor learning. Nat Rev Neurosci. 2011;12(12):739-751. doi:10.1038/nrn3112

12. Adams D, Logerstedt D, Hunter-Giordano A, Axe MJ, Snyder-Mackler L. Current Concepts for Anterior Cruciate Ligament Reconstruction: A Criterion-Based Rehabilitation Progression. J Orthop Sports Phys Ther. 2012;42(7):601-614. doi:10.2519/jospt.2012.3871

13. Rambaud AJM, Ardern CL, Thoreux P, Regnaux JP, Edouard P. Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review. Br J Sports Med. 2018;52(22):1437-1444. doi:10.1136/bjsports-2017-098602

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