Skip to main content
SpringerLink
Log in

Factors affecting return to sport following hamstrings anterior cruciate ligament reconstruction in non-elite athletes

  • Original Article • KNEE - SPORT
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Background

Anterior cruciate ligament (ACL) rupture is a common injury affecting non-elite and elite athletes. Although most ACL reconstructions restore the mechanical stability of the injured knee, the rate of return to sport (RTS) is varied.

Hypothesis/purpose

We aimed to identify why non-elite athletes fail to return to pre-injury sport level. The primary objective was to assess the frequency of RTS (including type of sport, timing, level, and duration), and the secondary objective was to assess the surgical (injury, type of surgery, re-injury) and patient (demographics, function, symptoms, social, psychological) factors affecting RTS, using a multivariate analysis.

Study design

Level III, retrospective cohort study.

Methods

We evaluated 78 consecutive non-elite athletes undergoing hamstring ACL reconstruction using medical records and questionnaires. Mean follow-up was 50 months (24–224 months). Athletes were divided into return to sport (RTS) and not returning to sport (NRTS) groups for comparative and multivariate analyses, to identify independent predictors of RTS status.

Results

Mean age was 31.5 years (18–51), and 46 were male (59%). The RTS rate was 56.4% (44), with most athletes returning between 9 and 12 months, and then continuing to play for > 60 months. Fear of re-injury was the highest reported reason for NRTS. There were no significant differences in demographics, concomitant injury, adjuvant surgery, and type of sport between the two groups. Mean Tegner scores were significantly higher in RTS group post-injury (6.9 vs 4.6) and at present (6.6 vs 4.6). The International Knee Documentation Committee (IKDC) score for the RTS group also increased significantly from pre-injury 70.8 (49.1–93.4) to 83.9 (24.1–100) post-injury (p < 0.001). Fear of re-injury, lack of confidence, lack of time, and change in job were significant factors in the NRTS group. Playing soccer, giving way, and change of job independently predicted RTS status from multivariate analysis.

Conclusion

A significant number of non-elite athletes did not RTS following ACL reconstruction, and this was influenced by a combination of activity level, sport, self-reported knee instability, and psycho-social factors. Importantly, some of these can be predicted and managed with improved, individualized post-operative physical and psychological rehabilitation programmes. These data also allow surgeons to better counsel athletes before ACL reconstruction on their likelihood of RTS.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Eastlack ME, Axe MJ, Snyder-Mackler L (1999) Laxity, instability, and functional outcome after ACL injury: copers versus noncopers. Med Sci Sports Exerc 31:210–215

    Article  CAS  Google Scholar 

  2. Dunn WR, Spindler KP, MOON Consortium (2010) Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a multicenter orthopaedic outcomes network (MOON) ACLR cohort study. Am J Sports Med 38:2040–2050. https://doi.org/10.1177/0363546510370280

    Article  PubMed  PubMed Central  Google Scholar 

  3. Griffin LY, Agel J, Albohm MJ et al (2000) Noncontact anterior cruciate ligament injuries: risk factors and prevention strategies. J Am Acad Orthop Surg 8:141–150

    Article  CAS  Google Scholar 

  4. Lentz TA, Zeppieri G, Tillman SM et al (2012) Return to preinjury sports participation following anterior cruciate ligament reconstruction: contributions of demographic, knee impairment, and self-report measures. J Orthop Sports Phys Ther 42:893–901. https://doi.org/10.2519/jospt.2012.4077

    Article  PubMed  PubMed Central  Google Scholar 

  5. Swirtun LR, Eriksson K, Renström P Who chooses anterior cruciate ligament reconstruction and why? a 2-year prospective study. Scand J Med Sci Sports 16:441–446. https://doi.org/10.1111/j.1600-0838.2005.00505.x

    Article  CAS  Google Scholar 

  6. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med 45:596–606. https://doi.org/10.1136/bjsm.2010.076364

    Article  PubMed  Google Scholar 

  7. Zaffagnini S, Grassi A, Marcheggiani Muccioli GM et al (2014) Return to sport after anterior cruciate ligament reconstruction in professional soccer players. Knee 21:731–735. https://doi.org/10.1016/j.knee.2014.02.005

    Article  CAS  PubMed  Google Scholar 

  8. Aglietti P, Giron F, Buzzi R, et al (2004) Anterior cruciate ligament reconstruction: bone-patellar tendon-bone compared with double semitendinosus and gracilis tendon grafts. A prospective, randomized clinical trial. J Bone Joint Surg Am 86-A:2143–2155

    Article  Google Scholar 

  9. Ardern CL, Webster KE, Taylor NF, Feller JA (2011) 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. Am J Sports Med 39:538–543. https://doi.org/10.1177/0363546510384798

    Article  PubMed  Google Scholar 

  10. Feller J, Webster KE (2013) Return to sport following anterior cruciate ligament reconstruction. Int Orthop 37:285–290. https://doi.org/10.1007/s00264-012-1690-7

    Article  PubMed  Google Scholar 

  11. Gobbi A, Francisco R (2006) Factors affecting return to sports after anterior cruciate ligament reconstruction with patellar tendon and hamstring graft: a prospective clinical investigation. Knee Surg Sports Traumatol Arthrosc 14:1021–1028. https://doi.org/10.1007/s00167-006-0050-9

    Article  PubMed  Google Scholar 

  12. Kvist J, Ek A, Sporrstedt K, Good L (2005) Fear of re-injury: a hindrance for returning to sports after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 13:393–397. https://doi.org/10.1007/s00167-004-0591-8

    Article  PubMed  Google Scholar 

  13. Lee DYH, Karim SA, Chang HC (2008) Return to sports after anterior cruciate ligament reconstruction - a review of patients with minimum 5-year follow-up. Ann Acad Med Singap 37:273–278

    PubMed  Google Scholar 

  14. Ardern CL, Taylor NF, Feller JA, Webster KE (2012) Return-to-sport outcomes at 2 to 7 years after anterior cruciate ligament reconstruction surgery. Am J Sports Med 40:41–48. https://doi.org/10.1177/0363546511422999

    Article  PubMed  Google Scholar 

  15. Roos H, Ornell M, Gärdsell P et al (1995) Soccer after anterior cruciate ligament injury— an incompatible combination? A national survey of incidence and risk factors and a 7-year follow-up of 310 players. Acta Orthopaedica Scand 66:107–112. https://doi.org/10.3109/17453679508995501

    Article  CAS  Google Scholar 

  16. Smith FW, Rosenlund EA, Aune AK et al (2004) Subjective functional assessments and the return to competitive sport after anterior cruciate ligament reconstruction. Br J Sports Med 38:279–284

    Article  CAS  Google Scholar 

  17. Nwachukwu U, Voleti B, Berkanish R et al (2017) Return to play and patient satisfaction after ACL reconstruction: study with minimum 2-year follow-up. J Bone Joint Surg 99:720–725. https://doi.org/10.2106/JBJS.16.00958

    Article  PubMed  Google Scholar 

  18. Xie X, Liu X, Chen Z et al (2015) A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee 22:100–110. https://doi.org/10.1016/j.knee.2014.11.014

    Article  PubMed  Google Scholar 

  19. Hu J, Qu J, Xu D et al (2013) Allograft versus autograft for anterior cruciate ligament reconstruction: an up-to-date meta-analysis of prospective studies. Int Orthop 37:311–320. https://doi.org/10.1007/s00264-012-1720-5

    Article  PubMed  Google Scholar 

  20. Welling W, Benjaminse A, Seil R et al (2018) Low rates of patients meeting return to sport criteria 9 months after anterior cruciate ligament reconstruction: a prospective longitudinal study. Knee Surg Sports Traumatology, Arthroscopy 1–9. https://doi.org/10.1007/s00167-018-4916-4

    Article  Google Scholar 

  21. Hamrin Senorski E, Svantesson E, Beischer S et al (2018) Low 1-year return-to-sport rate after anterior cruciate ligament reconstruction regardless of patient and surgical factors: a prospective cohort study of 272 patients. Am J Sports Med 46:1551–1558. https://doi.org/10.1177/0363546518765120

    Article  PubMed  Google Scholar 

  22. Sofu H, Yildirim T, Gürsu S et al (2015) Short-term effects of partial meniscectomy on the clinical results of anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:184–187. https://doi.org/10.1007/s00167-014-2960-2

    Article  PubMed  Google Scholar 

  23. Murawski D, Van Eck F, Irrgang J et al (2014) Operative treatment of primary anterior cruciate ligament rupture in adults. J Bone Joint Surg 96:685–694. https://doi.org/10.2106/JBJS.M.00196

    Article  PubMed  Google Scholar 

  24. Flanigan DC, Everhart JS, Pedroza A, et al (2013) Fear of reinjury (kinesiophobia) and persistent knee symptoms are common factors for lack of return to sport after anterior cruciate ligament reconstruction. Arthrosc J Arthrosc Relat Surg 29:1322–1329. https://doi.org/10.1016/j.arthro.2013.05.015

    Article  Google Scholar 

  25. Sandon A, Werner S, Forssblad M (2015) Factors associated with returning to football after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 23:2514–2521. https://doi.org/10.1007/s00167-014-3023-4

    Article  PubMed  Google Scholar 

  26. Kostogiannis I, Ageberg E, Neuman P et al (2007) Activity level and subjective knee function 15 years after anterior cruciate ligament injury: a prospective, longitudinal study of nonreconstructed patients. Am J Sports Med 35:1135–1143. https://doi.org/10.1177/0363546507299238

    Article  PubMed  Google Scholar 

  27. Tjong VK, Murnaghan ML, Nyhof-Young JM, Ogilvie-Harris DJ (2014) A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction: to play or not to play. Am J Sports Med 42:336–342. https://doi.org/10.1177/0363546513508762

    Article  PubMed  Google Scholar 

  28. Coronado RA, Bird ML, Van Hoy EE et al (2018) Do psychosocial interventions improve rehabilitation outcomes after anterior cruciate ligament reconstruction? a systematic review. Clin Rehabilit 32:287–298. https://doi.org/10.1177/0269215517728562

    Article  Google Scholar 

  29. Tegner Y, Lysholm J (1985) Rating systems in the evaluation of knee ligament injuries. Clin Orthop Relat Res 198:43–49

    Google Scholar 

  30. Anon (2015) Survey Monkey [Online]

  31. Irrgang JJ, Anderson AF, Boland AL et al (2001) Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 29:600–613

    Article  CAS  Google Scholar 

  32. Czuppon S, Racette BA, Klein SE, Harris-Hayes M (2014) Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. Br J Sports Med 48:356–364. https://doi.org/10.1136/bjsports-2012-091786

    Article  PubMed  Google Scholar 

  33. Satku K, Kumar VP, Ngoi SS (1986) Anterior cruciate ligament injuries. To counsel or to operate? J Bone Joint Surg Br 68:458–461. https://doi.org/10.1302/0301-620X.68B3.3755441

    Article  CAS  PubMed  Google Scholar 

  34. Fabbriciani C, Milano G, Mulas P et al (2005) Anterior cruciate ligament reconstruction with doubled semitendinosus and gracilis tendon graft in rugby players. Knee Surg Sports Traumatol Arthrosc 13:2–7. https://doi.org/10.1007/s00167-004-0505-9

    Article  PubMed  Google Scholar 

  35. Mohtadi NG, Chan DS (2017) Return to sport-specific performance after primary anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med 363546517732541. https://doi.org/10.1177/0363546517732541

    Article  Google Scholar 

  36. Lai CCH, Ardern C, Feller JA, Webster KE (2018) Eighty-three per cent of elite athletes return to preinjury sport after anterior cruciate ligament reconstruction: a systematic review with meta-analysis of return to sport rates, graft rupture rates and performance outcomes. Br J Sports Med 52:128–138. https://doi.org/10.1136/bjsports-2016-096836

    Article  PubMed  Google Scholar 

  37. Everhart J, Best T, Flanigan D (2015) Psychological predictors of anterior cruciate ligament reconstruction outcomes: a systematic review. Knee Surg Sports Traumatol Arthrosc 23:752–762. https://doi.org/10.1007/s00167-013-2699-1

    Article  PubMed  Google Scholar 

  38. Kolt G (1996) Psychosocial factors and sports injury rehabilitation. Aust J Psychol 48:114

    Google Scholar 

  39. Thomeé P, Währborg P, Börjesson M et al (2006) A new instrument for measuring self-efficacy in patients with an anterior cruciate ligament injury. Scand J Med Science in Sports 16:181–187. https://doi.org/10.1111/j.1600-0838.2005.00472.x

    Article  Google Scholar 

  40. Thomeé P, Währborg P, Börjesson M et al (2008) Self-efficacy of knee function as a pre-operative predictor of outcome 1 year after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 16:118–127. https://doi.org/10.1007/s00167-007-0433-6

    Article  PubMed  Google Scholar 

  41. Frobell RB, Svensson E, Göthrick M, Roos EM (2008) Self-reported activity level and knee function in amateur football players: the influence of age, gender, history of knee injury and level of competition. Knee Surg Sports Traumatol Arthrosc 16:713–719. https://doi.org/10.1007/s00167-008-0509-y

    Article  CAS  PubMed  Google Scholar 

  42. Webster KE, Nagelli CV, Hewett TE, Feller JA (2018) Factors associated with psychological readiness to return to sport after anterior cruciate ligament reconstruction surgery. Am J Sports Med 46:1545–1550. https://doi.org/10.1177/0363546518773757

    Article  PubMed  PubMed Central  Google Scholar 

  43. Caborn DN, Johnson BM (1993) The natural history of the anterior cruciate ligament-deficient knee. A review. Clin Sports Med 12:625–636

    CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Medical College of Virginia at Virginia Commonwealth University, West Hospital, 1200 East Broad Street, 9th Floor, Richmond, VA, 23298, USA

    Nirav K. Patel

  2. Imperial College London, London, UK

    Sanjeeve Sabharwal

  3. Rothman Orthopaedic Institute, 925 Chestnut Street, Philadelphia, PA, 19107, USA

    Christopher Hadley

  4. Philadelphia College of Osteopathic Medicine, 4170 City Avenue, Philadelphia, PA, 19131, USA

    Erica Blanchard

  5. Fortius Clinic, London, UK

    Sam Church

Authors
  1. Nirav K. Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sanjeeve Sabharwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christopher Hadley
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Erica Blanchard
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sam Church
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nirav K. Patel.

Ethics declarations

Conflict of interest

Nirav K. Patel, Christopher Hadley, Sanjeeve Sabharwal and Erica Blanchard declare no potential conflicts of interest. Sam Church has declared a potential conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Patel, N.K., Sabharwal, S., Hadley, C. et al. Factors affecting return to sport following hamstrings anterior cruciate ligament reconstruction in non-elite athletes. Eur J Orthop Surg Traumatol 29, 1771–1779 (2019). https://doi.org/10.1007/s00590-019-02494-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-019-02494-4

Keywords

Search

Navigation