Searching for What Medical Literature Says About ACL Injury Rehab, and Implications for Derrick Rose

Posted on June 17, 2013 by

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Disclaimer:  I am not in the medical field whatsoever, unless you count being born to a nurse.

All I am is someone who can read and find key ideas.  I don’t know a lot of the specific terms that those in the field refer to, I have never seen any of the machines, techniques, in action but at the very least I can read and contextualize the larger findings in these articles.

I was just a Bulls fan caught up in the Derrick Rose debates of whether he should come back or sit out after having been “medically cleared” in February.

I leaned heavily towards the pro-choice sounding side of “it’s his body, he decides” against the ideas that “he should be out there playing, to complete his re-hab.”

One of the main thrusts of the argument against Derrick Rose was that “he did not complete his rehabilitation” which by implication in the Bulls board was synonymous with him returning to play in NBA games.

I get that Derrick would need to re-assimilate back into the pace of the NBA game.  The only way to do that would be by playing.

However, I left it at that.  I didn’t take his absence from the NBA court as necessarily one of him “disobeying doctor’s orders”, or even “deviating from medical science.”

Despite the medical clearance, and increasingly impatient media and fans as months passed, interviews with Derrick, those around him, the team have all been in support of his decision, at least in public.

But still that won’t placate the “he should’ve played to complete his rehab crowd.”

My position has been:  We don’t have a lot of information as fans to properly understand what did or didn’t happen.

Today, a free morning, I tried to understand a little more.  I decided to peer a bit into the research literature on ACL re-hab.

Here are tidbits of what I’ve found from what I felt were 5 articles strongly pertaining to Derrick Rose.  The list is more exploratory than exhaustive.

All are exact quotes unless otherwise noted.  All emphases are mine.

1.  Myer, Gregory D., Mark V. Paterno, Kevin R. Ford, Carmen E. Quatman, and Timothy E. Hewett. “Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-to-sport phase.” The Journal of orthopaedic and sports physical therapy 36, no. 6 (2006): 385.

Quick Summary:  This article makes a suggestion on how ACL recovery should progress in stages.  The exact points of progression mentioned in the article probably would not be well-understood by the non-specialist because it’s based on whether or not the athlete can reach percentages and measures doing certain exercises on certain machines/monitors.

One thing we non-specialists could understand is the recommendations for the course of action athletes should take after those measures have or have not been reached.

In relation to the fan talk about Derrick Rose, it seems that he may have achieved a “functional stability” to be “medically cleared” but may not have had sufficient strength in his knee to build upon as evidenced by his unwillingness to play until he reached certain benchmarks.
Being “medically cleared” was interpreted as “having no significant chance of re-injury than any other player,” which seems to mask any pain that may actually be telling him “don’t play, don’t play!”
Derrick also reported some pain after having been medically cleared, which most of the Bulls board took as ‘normal’ and grounds for him to “play through.”
  • Return of a patient to high-level sports before functional stability is achieved may increase the potential for poor outcome. In addition, inadequate functional stability may be related to decreased confidence in the injured knee and to decreased ability to return to preinjury sports participation. (387)
  • The absence of sufficient strength may result in an inability to initiate dynamic movements, to attenuate ground reaction forces, or to achieve high levels of performance during dynamic tasks. (387)

  • The final stage of return-to-sport training focuses on skill reacquisition related to the athlete’s sport and to maximize athletic development during training. More specifically, stage 4 of the return-to-sport protocol will focus on the following: (1) equalizing ground reaction force attenuation strategies between limbs; (2) improving confidence and stability with high intensity change of direction activities; (3) improving and equalizing power endurance between limbs; and (4) using safe biomechanics (increased knee flexion and decreased knee abduction angles) when performing high-intensity plyometric exercises (394).
  • Successful completion of stage 4 and ultimate clearance for integration back into sporting activities is dependent upon the athlete’s ability to achieve the following criteria related to sport-specific movements: (1) drop vertical jump landing force bilateral symme- try (within 15%) (Figure 6); (2) modified agility T-test (MAT) test time (within 10%) (Figure 7); (3) single-limb average peak power test for 10 seconds (bilateral symmetry within 15%) (Figure 8); (4) reassessment of tuck jump (20 percentage points of improvement from initial test score or perfect 80- point score) (Appendix 2; Figure 5). (394)

  • Athletes following ACL reconstruction demonstrate deficits up to 20% or more on their involved limb.70 We recommend that athletes achieve 85% or better side-to-side symmetry in the average force production to progress beyond this stage of rehabilitation. Athletes unable to perform the single-limb power hop with symmetry (greater than 15% deficit) may be affected by residual pain or strength deficits that warrant further rehabilitation prior to re-entry into sport activities. (395)
  • Once athletes meet the stage 4 criteria, they should be prepared to leave therapy and begin reintegration into their respective sports. However, we do not suggest that this is the time for unrestricted full participation in competitive events; rather, it is suggested that athletes resume practice activities and begin to prepare themselves for competitive play. Return to sport following ACL reconstruction can be a high-risk period for athletes after ACL reconstruction because of both the risk of graft failure and the increased risk of injury to the contralateral limb, which may be higher than the involved side.30,82 Retear rates may reach as high as 20% in young patients.81 There is also the potential for long-term osteoarthritic changes that occur in the majority of both ACL-deficient and ACL-reconstructed knees.

2.  Ardern, Clare L., Kate E. Webster, Nicholas F. Taylor, and Julian A. Feller. “Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction Surgery Two-thirds of Patients Have Not Returned by 12 Months After Surgery.” The American journal of sports medicine 39, no. 3 (2011): 538-543.

Quick Summary:  This article talks about how a lot of athletes still don’t go back to their sports, even after 12 months post-surgery.  It’s a reply to people who thought that Derrick not returning in 12 months was somehow abnormal.

  • Current trends in rehabilitation after ACL reconstruction surgery are for the provision of programs emphasizing early weightbearing and the immediate commencement of exercises to restore knee range of motion and muscle strength. Return to sport may be permitted as early as 4 to 6 months postoperatively.11 Athletes typically receive clearance to return to sport after ACL reconstruction surgery around 6 to 12 months postop- eratively,2,11 and most are expected to return to sport within 12 months after surgery.14 As such, it is important to have information regarding the efficacy of ACL reconstruction surgery in terms of achieving the desired aim of returning an athlete to sports participation at 12 months. (538)
  • if a successful return to sport is defined as a return to the preinjury sports partici- pation level, the findings of the current study suggest that many athletes may require a longer period of postoperative rehabilitation to ensure a successful return to sport. This is supported by the finding that approximately 50% of the participants in the current study who had not returned to competitive sport at follow-up indicated that they intended to return to sport. (542)

  • The seasonal nature of competition in some sports appears to have some influence on the return-to-sport rate. Patients in this study were significantly more likely to have attempted full competition in seasonal sports at follow-up when compared with year-round sports. The reasons for this difference are unclear. However, it could be that seasonal competition gives a more definitive target date for returning to sport. For example, the athlete may target the first game of the season for his or her return to competition.
3.  Wilk, Kevin E., LEONARD C. Macrina, E. LYLE Cain, JEFFREY R. Dugas, and JAMES R. Andrews. “Recent advances in the rehabilitation of anterior cruciate ligament injuries.” J Orthop Sports Phys Ther 42, no. 3 (2012): 153-171.
Quick Summary:   This article gives an actual criteria for returning to play after ACL surgery.
  • Although we expect all our patients to return to unrestricted activities and preinjury levels after surgery,5,6,162 some authors have reported some concerning results in which professional football players’ careers have been altered and even shortened by approximately 2 years and their overall performance has decreased by 20%.
  • Criteria for Return to Play (160)

    1. Satisfactory clinical examination
    2. Symmetrical range of motion without pain 3. Isokinetic test parameters

    • Quadriceps bilateral comparison (80% or greater)
    • Quadriceps torque-body weight ratio (65% or greater)
    • Hamstrings-quadriceps ratio (>66% for males, >75% for females) • Acceleration rate at 0.2 s (80% of quadriceps peak torque)

    4. KT 2000 test within 2.5 mm of contralateral leg
    5. Functional hop test (85% or greater of contralateral side)

  • If the patient’s knee is still sore or exhibits swelling after running, stiffness, or local- ized pain, the activities are reduced to a level that does not produce these effects (160).
4.  Myklebust, G., and R. Bahr. “Return to play guidelines after anterior cruciate ligament surgery.” British Journal of Sports Medicine 39, no. 3 (2005): 127-131.

 Quick Summary:  This article basically tells doctors to be cautious about their patients’ long-term health.

  • As shown above, most elite athletes are initially able to resume their sports career. However, the data also show that the retirement rate may be higher among athletes with a previous ACL injury compared with healthy athletes. Furthermore, it is apparent that there is a significant risk of reinjury to the graft, as well as the menisci and cartilage with continued sports participation. Finally, there are convincing data to show that nearly all patients will develop OA [osteoarthritis] with time (130).
  • Thus it seems reasonable to question whether return to high level pivoting sports really is in the athlete’s best interest—if long term knee health is the primary concern. The relevant issue that needs to be addressed is: what are the additional risks of further injuries and early OA associated with return to sport? We cannot answer this question properly from the available data. Until we can, as physicians and physiotherapists working with this patient group, it is our obligation to provide adequate information of the potential consequences of returning to pivoting sports. We must enable the athlete to make an informed decision with all necessary information available, including the caveats related to future risk of knee problems and OA. This includes clearly pointing out that ACL surgery can only be expected to improve knee stability, but that ACL surgery does little or nothing to secure a future healthy knee (130).
5.  McCullough, Kirk A., Kevin D. Phelps, Kurt P. Spindler, Matthew J. Matava, Warren R. Dunn, Richard D. Parker, Emily K. Reinke et al. “Return to High School–and College-Level Football After Anterior Cruciate Ligament Reconstruction A Multicenter Orthopaedic Outcomes Network (MOON) Cohort Study.” The American Journal of Sports Medicine 40, no. 11 (2012): 2523-2529.
Quick Summary:  An article centered on high school and college football players and how a significant chunk report not being able to perform at a level attained before their ACL tear.
  • Based on player perception, 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all. Although two thirds of players reported some “other interest” contributing to their decision not to return, at both levels of competition, fear of reinjury or further damage was cited by approximately 50% of the players who did not return to play.
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