Return to Play After an Anterior Cruciate Ligament Injury: Prioritizing Neurological and Psychological Factors of the Decision-Making Algorithm
TAKE-HOME POINTS
- The CNS demonstrates neurophysiological changes during an ACL injury.
- Traditional orthopedic treatment based on principals of musculoskeletal rehabilitation may not be sufficient to address CNS deficits.
- The CNS is neuroplastic and able to change with neuromotor rehabilitation that focuses on the CNS.
- Psychosocial factors may contribute to impairments after an ACL injury, and adversely affect functional outcomes.
- Assessment of RTP criteria should consider psychosocial, and central neural factors to minimize risk, and optimize outcomes.
Although anterior cruciate ligament (ACL) rehabilitation has evolved considerably over the past 2 decades, the basic paradigm has remained consistent: normalize strength and range of motion, reduce swelling and pain, achieve limb symmetry with functional tasks, and return to sport-specific activities gradually over a 6 to 12-month period. There have been some slight additions to this basic premise, such as evaluating knee and hip mechanics in the frontal plane, but the requirements here are vaguely defined and are typically only evaluated within the context of controlled clinical testing.
It is interesting to note that the typical ACL injury pattern occurs during a normal sport-specific movement, yet most rehabilitation protocols fail to recognize the potential causes of the aberrant movement pattern and how to best modify it so that the risk of repeated stress to the ACL can be minimized. It should be understood that movement occurs through the interaction of 3 discrete factors: the individual, the task being performed, and the environment in which it is performed.1 All of these factors will play a role in how the final movement pattern is produced. For example, a soccer player (individual) may backpedal and pivot to the left 60° and accelerate to sprint after a player moving towards the touchline (task) while receiving instructions from teammates and monitoring the movements of opposing players (environment). A small variance in any 1 of these factors could significantly impact the movement pattern as the player completes the task.
In most rehabilitation programs, each of these factors may be treated in a singular, non-specific manner, but if these factors are not coordinated effectively throughout the program to produce the desired sport-specific movement, a faulty pattern may persist, leaving the player at risk for injury. Current rehabilitation programs seem to have a strong focus on creating stability, mobility, and strength, but these are trained in silos, with an internal focus of control, which only solves the biomechanical equation. Often, it is difficult for the player to coordinate good biomechanics into an efficient, protective movement pattern that is specific to the tasks performed on the field during the normal course of play. The missing link here is the central nervous system (CNS).
Limitations to the current ACL protocols may be that they rely heavily on musculoskeletal rehabilitation and that they have limited emphasis on neurological rehabilitation. As will be discussed later, the CNS has a large impact on the final movement selected by the player. In fact, cognition, perception, and action are the three factors that comprise the individual’s part of the movement paradigm,1 yet rarely are these factors addressed in most ACL rehabilitation programs. These elements are a large part of the movement equation, so it is easy to understand how failing to address these features can lead to poor movement quality and subsequent ACL re-injury.
In addition to central neurological factors, cognitive issues may play a role in the player’s ability to return to sport. Determining optimal readiness for return to play is a difficult task for the medical community, with many variables to consider. Previous research studies have assessed the variability in return to play for various sports, including football, rugby, soccer, skiing, running, and tennis, with return-to-play rates ranging from 18% to 100%.2,3,4-10 The risk of secondary injury may cast doubt and fear on athletes as they contemplate their successful return to play.8,11 Although robust functional testing has become commonplace for determining athlete readiness after injury,12-20 the assessment of psychological readiness, persistent fear, and loss of confidence are often neglected and not as commonly integrated into the return-to-play algorithm.21-24 The purpose of this paper is to assess the various cognitive and central neural factors affecting a soccer player’s ability to recover from an ACL injury and offer suggestions for integrating treatments into the protocols to address these issues.
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