Use of limb symmetry as criteria for safe return to play after knee surgery

David Logerstedt, PT, PhD, MPT, MA, SCSUniversity of Delaware, Newark, DE

Disclosure

• I have no disclosures

Learning Objectives1. Clinicians will understand the risks of reinjury upon

returning athletes to their sports.2. Clinicians will understand specific considerations for

return to sport decision making3. Clinicians will learn clinical decision making

strategies for a progressive and safe return to high demand sports activities

4. Clinicians will know general recommendations for determining whether an athlete should be allowed to return to play

Return to play criteria• Hot topic• Increasing number of articles discussing this

topic

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Goals of Knee surgery

• Repair/reconstruct pathoanatomic structures– Restore passive mechanical stability– Remove mechanical blocks– Repair damaged cartilage

• Reduce pain• Restore knee function• Return to previous levels of activity

Incidence of reduced knee function after surgery

ACL reconstruction– 22-28% poor knee

function at one year(Hartigan 2010, Logerstedt 2012)

– 37% do not return to sport

– 56% do not return to competitive sport

(Ardern 2011, Ardern 2011)

• Meniscetomy/meniscus repair– 22% of medial

meniscetomy, 53% of lateral meniscectomy had pain and/or effusion after RTS

(Kim 2013)

– Similar pain and QoL 4 years after meniscetomy compared to OA group

(Thorlund 2012)

• Chondral surgery– 34-41% after

microfracture do not return to competition

(Harris 2010, Mithoefer 2006, 2009)

– 4-66% after ACI do not return to sport (20-40% do not return to same skill level)

(Mithoefer 2005, Mithoefer 2012)

Incidence of reinjury after knee surgery• Risk of recurrent injury associated with

previous injury (Hamilton 2011, Meeuwisse 2007)

Reinjury rates

– ACL reconstruction• 7-49% (Barber-Westin 2011, Patterns 2010, Shelburne 2009)

• 15x greater than controls in 1st year, 6x greater in 2nd year (Patterns 2013)

– Meniscetomy/meniscus repair• In elite athletes, 24% failure rate at mean

42 months after meniscal repair (Logan 2009)

– Chondral Surgery (microfracture, ACI)• Return to jumping, cutting, pivoting

sports increase risk for PTOA (Ding 2005, Kujala 1995)

Terrell Thomas

Risk factors• Functional asymmetries

– Quadriceps weakness – Poor hop performance– Balance and reach

(Ericsson 2006, Palmierei-Smith 2008, Van Assche 2010, Logerstedt 2012)

• Self-reported knee function

(Czuppon 2013, Lentz 2012)

• Kinematics and kinetics(Di Stasi 2013, Roewer 2011)

Decision-based RTP model (Creighton 2010)

Symptoms

Physical Exam (Impairments)

Performance-based measures (Activity Limitations)

Return to sports criteria• No consensus

(Barber-Westin 2011, Narducci 2011, Shultz 2013, Thomee 2011)

• Ensure fully rehabilitated and meet the demands of their sport

(Hartigan 2010, Barber-Westin 2011, Thomee 2011)

• Reduce risk for reinjury

Recommendations

• Several recommended criteria – European Board of Sports Rehabilitation (Thomee 2011)

Type of Sport LSI strength LSI hop performance

PivotingContactCompetitive

100% Knee extensorAnd

100% Knee flexor

90% on two maximum And

one endurable

Non-pivotingNon-contactRecreational

90% Knee extensorAnd

90% knee flexor

90% on one maximumOr

one endurable

Criteria at University of Delaware

Fitzgerald 2000, Hartigan 2010, Di Stasi 2013

Related to

• Gait asymmetries(Di Stasi 2013)

• Self-report knee function(Logerstedt in review)

• Return to Activity(Nawasreh in review)

Measures Accuracy 95 % Confidence Interval

Sensitivity 90.8% 85.4, 96.1%Specificity 47.6% 33.1, 62.0%Positive predictive value 61.6% 50.7, 72.5%Negative predictive value 84.8% 77.0, 92.6%Positive likelihood ratio 1.73 1.39, 2.15Negative likelihood ratio 0.19 0.09, 0.41

Strategies

• Restore symmetrical strength, knee performance, and sports mechanics

(Mithoefer 2012, Adams 2012, Myer 2006)

• Prevention strategies(Di Stasi 2013, Hewett 2013, White 2013)

Strategies

• Progression sports skills(Mithoefer 2012, Adams 2012, Myer 2006)

• Plyometrics/Functional performance enhancement

(Lorenz 2010, 2011, Redman 2011)

Conclusions

• Limb symmetry may be important indictor to enhance outcomes and reduce disability

• Use of test battery with performance-based and patient-reported outcome measures can identify asymmetries

• Systemic progressive rehabilitation can improve outcomes