McMaster University is seeking athletes who have had ACL reconstruction surgery to complete its online survey to gauge more information on the serious injury many basketball players face.  The survey involves 19 questions and will take 5-10 minutes to complete.  If you have had ACL reconstruction surgery to your knee injured while playing basketball or any other sport in the last 6-18 months, Basketball Manitoba encourages you to participate in the anonymous study.  More information and a link to the online survey can be found at...


This study is being targeted to patients who have had their ACL reconstructed within the last 6 to 18 months, as part of a Master’s research thesis project.  Information gleaned from the survey may help inform the future development of Clinical Practice Guidelines in establishing return to play readiness in athletes following ACL reconstruction. 


Participation in the survey involves answering 19 questions about their activity level, their experience surrounding the process of rehabilitation after ACL reconstruction, and their decisions surrounding returning to sport.  The questionnaire will take 5-10 minutes to complete.

The primary goals of this study are:

  1. To establish a baseline of current attitudes and practice amongst surgeons and physiotherapists in Canada in making return to play decisions following ACL reconstruction

  2. To determine the differences in clinical variables (demographic, subjective, and psychological) between athletes who return to pre-injury level of sport participation, and those who do not at short term follow up, and

  3. To gain a better understanding of how athletes and clinicians define successful return to sport and if any discrepancies in expectations exist between these groups.



Ethical approval has been obtained by McMaster University for distribution of this survey. 




Anterior cruciate ligament (ACL) injuries are one of the most common orthopaedic sports injuries, and significant burden on the athlete in terms of pain, disability, loss of sporting and social activity, and a financial burden due to medical costs and potential loss of income.  ACL reconstruction is widely perceived as the only viable way to restore stability and functional biomechanics of the knee, thus allowing the athlete to successfully return to playing their sport.  Despite the majority of athletes achieving good functional outcomes as measured by impairment and disability scales, many of them do not return to pre-injury level of sporting activity.  This discrepancy suggests that additional factors other than satisfactory physical outcomes are at play in determining return to sport readiness.  The surgical aim of ACL reconstruction is to restore the stability and functional capacity of the ACL deficient knee.  The focus of the physiotherapist is to maximize the strength and physical ability of the patient by normalizing the strength, range of motion, and functional biomechanics associated with movement.  


It is concerning that only between 20% and 50% of those athletes who have sustained an ACL injury return to the same sports following ACL reconstruction (Gobbi and Francisco, 2006; Kvist and Ek, 2005; Lee et al., 2008, Wiger et al, 1999).  Moreover, of those athletes who do return to athletic activities, 10% to 70% of the athletes continue to experience significant functional limitations, and resume at a lower level of sports participation (Smith et al., 2004).  Clearly, restoring the stability of the knee with reconstructive surgery does not guarantee the preinjury status of high level sports participation.  Lentz et al. (2009) suggests that incomplete rehabilitation may be a factor in the failure to return athletes to preinjury athletic participation, if athletes are allowed to return to play prior to their impairments being sufficiently resolved.  The current paucity of evidence to support optimal rehab status makes it difficult to make evidence based decisions.  Unfortunately, standardized clinical guidelines do not exist to assist clinicians in making return to play decisions, and little consensus exists on which outcome measures best evaluate an athlete’s functional status.  Furthermore, the preponderance of research in the development of postsurgical outcome measures focuses on measures of impairment and disability.  Interestingly, measures of impairment, which clinicians have traditionally relied upon to make return to play decisions, show little correlation with measures of function (Lephart et al., 1992). It is also arguable, that these measures of impairment do not accurately represent the ability of an athlete to perform in his or her sport successfully.   It is time that standardized measures, which are pivotal in the decision making scheme of athletic participation, reflect the WHO’s International Classification of Functioning, Disability and Health (ICF), and incorporate measures of participation.  There exists a strong need to establish a correlation between functional and subjective outcome measures and return to play readiness at the level of sport participation in order to develop standardized clinical decision guidelines.  This is especially necessary given the evidence that clinicians are making decisions based on standard physical characteristics, such as strength, ROM, laxity, girth, and swelling, which have been shown to correlate poorly to function (Lephart et al., 1992).  This puts into question the validity of current measures of evaluating postoperative levels of sport participation, such as the Cincinnati Knee Rating Scale, whose constructs are based on these measures of impairment, in establishing return to play readiness.  The CKRS, perhaps the best validated outcome measure, while demonstrating high reliability and validity in patients following ACL reconstruction (Barber-Westin et al., 1999), fails to establish a correlation between level of impairment and readiness for high level sports participation.  Functional performance tests are most commonly used to evaluate an athlete’s functional status, with the underlying assumption that tests of physical performance simulate stresses about the knee experience during athletic activity.  In the absence of strong research that validates their correlation with level of athletic participation, caution should be exercised in the interpretation of any results beyond the level of disability in patients following ACL reconstruction.  Uniquely, Ardern et al. (2011) investigated the relationship between hop tests and return to preinjury levels of activity in patients following ACL reconstruction, and observed a high correlation between levels of performance on functional tests and return to preinjury levels of activity.  Clearly further research is warranted in further investigating the relationship between functional performance measures and participation in preinjury levels of sport.  


Clinical experience suggests that discordance exists between medically directed return to play decisions, the validity of the evaluation criteria, and patient perceived readiness.  Given the complex nature of physical and mental demands on athletes to perform successfully in sports, it makes sense that a complex diagnostic tool be validated that correlates multidimensional deficits with measures of participation.  Lentz et al. (2009) have suggested that both self-report and performance based measures be used to evaluate function, as they can come to different conclusions.  The International Knee Documentation Committee score is a universally accepted and well validated self reported measure used in the evaluation of postsurgical outcomes of the knee due to its high test-retest reliability and convergent validity.  The test’s validity as a measure of athletic readiness has been called into question, however, since Lephart et al. (2002) were unable to demonstrate a correlation between test scores and return to play readiness in athletes following ACL reconstruction.  The Patient Specific Functional Scale, which investigates the functional status of a patient by rating up to 5 activities with which they have difficulty (Stratford, 1995), may be a more sensitive self report measure as the athletic tasks chosen may be more meaningful than other generic or disease specific measures.


Given the extensive personal burden of pain and disability following an ACL injury, it is arguable that fear of reinjury is a psychological variable with the potential to impede RTP after ACLR (Kvist et al., 2004).  Indeed, a high fear of reinjury has been correlated with a poor self report of function (Kvist, 2005).  Exploring the relationship between kinesiophobia and sports with the Tampa Scale for Kinesiophobia, Kvist et al.(2005) demonstrated high TSK scores to be correlated with subjects with decreased activity levels compared with those who had resumed preinjury levels of sports participation.   Recently, the ACL-RSI has been introduced as a further measure to evaluate the psychological impact of returning to sport after anterior cruciate ligament (ACL) reconstruction surgery (Webster et al., 2008).  Thus the potential role of kinesiophobia as a determinant in the return to play readiness of athletes following ACL reconstruction warrants further investigation. 


Implicit in the question of whether an athlete is ready to resume sporting participation is how soon this can be accomplished.  There is currently no consensus as to when an athlete can or should return to play.  With a push to accelerate rehabilitation, discrepancies between return to play protocols may vary between 4 months and 12 months postoperatively (Cascio et al., 2004, Kvist et al., 2004).  These decisions seem increasingly based on the desire to resume athletic activity, and not a strong evidence based practice.  With surgeons, and athletes alike pushing the boundaries of accelerated return to play following an ACL injury, the measure of successful rehabilitation is increasingly how fast the athlete resumes their athletic career. This begs the question: Are we returning our athletes to play too soon, and with insufficient evidence to support our decisions?  A clear understanding of which measures are associated with successful participation in pre-injury levels of sporting activities is crucial to the development of evidence-based clinical decision rules in returning athletes to play. 


The purposes of this study are to (1) establish a baseline of current attitudes and practice amongst surgeons and physiotherapists in Canada in making return to play decisions following ACL reconstruction, (2) determine the differences in clinical variables (demographic, subjective, and psychological) between athletes who return to pre-injury level of sport participation, and those who do not at short term follow up, and (3) to gain a better understanding of how athletes and clinicians define successful return to sport and if any discrepancies in expectations exist between these groups.


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