Latest / UF Health MedEd Cast / When Can I Play Again? - The Science of Return to Sport

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When Can I Play Again? - The Science of Return to Sport · UF Health MedEd Cast

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  Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.
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  And today, we're highlighting the science of return to sport.
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  Joining me is Dr.
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  Joshua Reside.
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  He's a fellowship-trained orthopedic surgeon and sports medicine
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  specialist at the University of Florida College of Medicine.
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  Dr.
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  Reside, thank you so much for joining us today.
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  When an athlete, for example, tears their ACL, one of the first things they always
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  want to know is when can I play again?
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  This is a big deal in sports today, whether it's, you know, soccer players or
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  high school, collegiate, or even the pros.
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  What does return to play actually mean when we're looking at a
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  professional such as yourself?
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  Dr. Joshua Reside:
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  Yeah.
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  Thanks for having me, Melanie.
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  You know, it's one of those injuries that is very common, especially in our
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  high school athlete population that I mostly see in our Ocala, Florida area.
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  And what an ACL tear is is basically the ACL is a dynamic stabilizer of the knee.
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  And it's for pivot, change of direction, rotation.
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  And so, when the ACL tears, you know, it's really important that
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  we fix the ACL, and we usually do that through a reconstruction.
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  There are some repair techniques that we can use, but usually a reconstruction,
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  which means using either a graft tissue from your own body or allograft tissue,
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  or other known as cadaver tissue.
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  So in our high school athletes, it's mostly going to be autograft tissue,
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  and I like to use either the quadriceps tendon or the patellar tendon with
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  a couple of bone plugs on each end.
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  And the biggest thing when patients come in with an ACL tear,
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  obviously, we talk about all those things that I just mentioned.
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  But usually, what's on the mind of the athlete is how long are they
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  going to be out of sports, and when can they come back to playing?
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  And I think it's a pretty complicated response to that,
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  because there's so many things that go into returning back to sports.
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  And then, what does returning back to sports actually mean?
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  And so, what I mean by that is, you know, if you're a football player
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  and you're playing in high school.
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  And let's say you're even being recruited for college, returning back to sports
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  isn't just getting back and putting your pads on and sitting on the sidelines.
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  Returning to sports is going to be for me, going back to
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  performing at that same level.
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  And so, I think there's sort of three phases to returning to sports.
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  It's, you know, returning to participation in that sport, returning to competitive
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  play in that sport, and then returning to the same performance level in that sport.
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  And I think there's a lot that goes into that.
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  You know, there's a timeline that we use for all this, which usually gives us
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  a good indication of biological healing.
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  But that timeline of things doesn't necessarily predict how much muscle
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  you'll have in your quadriceps to be able to go back to play.
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  It doesn't tell us if you're psychologically ready to go onto the
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  field and do what you need to do to return to that sport without doing those
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  same sort of motions, the cutting, the pivoting that caused the injury to happen
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  in the first place, there's sometimes a little bit of trauma, you know, in
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  that athlete's mind to do those same sort of maneuvers that eventually led
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  to them having a very serious injury.
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  There's limb symmetry.
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  So after an injury, after an ACL tear, there's quite a bit of quadriceps
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  strength loss in the knee, and that's also sort of multifactorial.
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  There's arthrogenic muscle inhibition.
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  There's also just some atrophy of the muscle, because the
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  quadriceps muscle gets weak.
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  And so, all of these things sort of play into returning back to sports.
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  And these are all conversations I like to have with the athlete when
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  I first see them in the office to sort of give them a timeline of what
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  to expect after they have surgery.
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  The first six weeks after, what do the first three months look like?
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  When can they get back to jogging?
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  So, we talk about all those things in the preoperative visit, discussing
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  the types of grafts and when to expect to come back to sports.
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  And on top of all that, we also get some objective testing where we look at
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  the strength in the operated leg versus the unoperated leg, and we try to get
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  those pretty close to being back to normal before that athlete goes back.
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  So, very multifactorial, and I'm just sort of touching the tip of the iceberg
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  on each one of those sort of topics that plays into returning back to sports.
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  Melanie Cole, MS: That was a very comprehensive answer, Dr.
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  Reside.
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  You and I could really talk about this for a long time.
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  It's a hot topic in sports today.
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  It really is.
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  And since the road to recovery is really never the same for two people, and the
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  sport they're returning to certainly would affect your criteria as you're telling us
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  about the milestones that you look for.
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  What are some of the major factors that you see that inhibit recovery?
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  Now, you mentioned psychological readiness, and we are going
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  to get into that for sure.
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  And strength, symmetry, quality, confidence, I mean, there is a whole
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  lot that goes into it, as you say, but what are some of the factors
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  that inhibit that recovery when we're looking for the criteria that
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  you use to determine readiness?
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  Dr. Joshua Reside:
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  Yeah.
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  We usually get patients into physical therapy right away.
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  And sometimes some of the inhibition to someone's rehab is actually
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  getting access to physical therapy.
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  We oftentimes will run into issues with insurance companies not paying for
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  physical therapy visits, and families have to make tough decisions about paying out
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  of pocket for certain physical therapy costs and how often they're going as far
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  as once a week or once every other week.
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  And so, that's one that I'll commonly see, especially in our population down
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  here in Ocala is there's a little bit of inhibition with sometimes physical therapy
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  being covered by insurance companies.
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  And I've had some patients where it's been a struggle to keep them consistent
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  with the rehab and progression through all of that without the
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  guidance of a physical therapist.
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  And so, physical therapists play a huge role in recovery.
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  And along those same lines, the athletic trainers at the school do a fantastic
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  job getting those athletes ready.
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  And it comes down to those athletes buying into the rehab and owning it
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  as far as them having to actually show some ownership in their recovery to
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  get back to the level that they want to as far as performance in their sport.
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  And so, I would say that would be probably the biggest inhibitors to getting back.
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  or having access to a gym to work on their strengthening having time during
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  their school days and transportation to and from not just physical
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  therapy, but a gym they may be using.
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  And then, sometimes just biology.
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  Sometimes with an ACL tear, we'll also see meniscus tears.
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  We'll see collateral ligament injuries with the MCL or LCL.
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  We'll see multiligamentous knee injuries.
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  All of those sort of things can—I wouldn't necessarily say inhibit, but
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  sort of delay their recovery to coming back to a sport and sometimes prevent
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  them even from coming all the way back to the same performance level.
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  And so, those are just some of the reasons I can think of that at least I've seen as
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  far as patients being inhibited or going back to participating in their sport.
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  Melanie Cole, MS: Yeah.
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  So, let's talk about sports psychology here, which in itself
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  is also now a burgeoning field that we're learning more and more about.
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  So, speak about the mental side of returning, Dr.
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  Reside.
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  So, fear of re-injury, obviously confidence, those things affect readiness.
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  We've learned that athletes can be physically capable,
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  but psychologically hesitant.
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  So, how can physicians, therapists, athletic trainers, coaches, even
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  the parents of athletes work together to assess whether a
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  player is psychologically ready?
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  What do you do when you're speaking to these professionals and
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  helping them to guide the athlete?
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  Dr. Joshua Reside:
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  When I give a clearance for somebody to go back to playing their sport, a
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  medical clearance, that's very different than being ready to go back to play.
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  So based on our numbers and based on our objective findings and our
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  physical findings, you're right, sometimes patients are ready to go back.
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  And so, there's been a lot of research in this area, and there are some things
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  and some tools that I can use as a surgeon to help assess that readiness.
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  Some of those things are questionnaires.
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  Some of that is just my assessment, talking with the patient, asking them,
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  you know, if they're ready to go back and sort of if they're ready or what
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  concerns they may have about going back.
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  But it really is a team approach to going back to this.
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  And what I mean by that is I want to know what their physical therapist
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  thinks when they're watching them do their exercises as they go back.
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  And so, oftentimes at the end of their rehab, we'll have them
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  return back to pivoting and changing direction and rotating.
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  And they'll do those things in front of their physical therapist.
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  And I want to know what their physical therapist thinks if there
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  looks like there's any hesitation.
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  Another huge advantage that we have is our athletic trainers at our high schools in
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  Ocala at least they know these athletes.
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  They are with them at practices.
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  They're with them at games.
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  They know how these athletes move normally and what their baseline is.
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  And so, I really rely on their judgment as far as, you know, watching these
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  athletes as they recover to get back to doing the same things that they were
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  doing before and doing it in a safe way.
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  There's a lot, I think, that goes into that.
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  And then, I think the last thing that I'll mention is when we talk about
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  going back to playing sports, there's a little bit of a controversy on whether
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  or not bracing will make a difference.
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  And so, we'll oftentimes order a brace.
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  In the literature, there's been no findings that have shown that
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  the brace prevents any re-injury of the ACL graft specifically.
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  But there are some studies that show that, psychologically, it may help
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  patients and athletes get back to playing just having the brace on.
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  On the flip side of that, there are some studies that argue that having
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  that brace on may change the way that the athlete would normally move.
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  And so, it's definitely controversial.
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  And usually towards the end of the rehab, I'll have a conversation
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  with the patient to see if they're interested in wearing a brace.
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  And I would say most of my patients usually feel more comfortable
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  going back to playing at least starting with the brace on.
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  And then, over time, they may find it easier to get
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  around and to move without it.
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  But all of those things sort of play into getting an athlete
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  psychologically ready to go back to play.
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  Melanie Cole, MS: Yeah, bracing is an interesting topic in itself, right?
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  So when we think of re-injury, Dr.
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  Reside, can we predict who's going to be at a higher risk of tearing their ACL?
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  I suppose that some of it's going to be adherence and compliance, as
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  you said, physical therapy, making sure that they're doing prehab before
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  surgery and, you know, rehab afterwards and really keeping up with that.
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  But what do you see most often when re-injury happens?
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  Does it happen too quickly?
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  Are they not ready?
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  Tell us what you see.
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  Dr. Joshua Reside:
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  Yeah.
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  So, there's a lot of different reasons that that can happen as well.
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  You mentioned prehab and things like that.
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  I think that's always really important.
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  I tell patients that, after surgery, we know that there's
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  going to be atrophy of the muscle, the quadriceps muscle especially.
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  We know that there's going to be some stiffness in their knee as
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  far as range of motion that we'll have to get through with rehab.
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  So, I always tell patients that, before we even do the surgery, wherever we
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  start as far as our strength and our range of motion, we know that there's
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  going to be a dip after surgery.
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  And so if we can start that in a better spot be a little bit stronger, make
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  sure our range of motion is in a really good place, then that dip that we have
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  after surgery won't be as far down if we prepare the knee with prehabilitation.
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  So, I think that's where that comes in, and that can even sort of get us in a
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  better starting point when we start our rehab, which can definitely speed things
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  along as far as that recovery timeline and getting back to where we need to.
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  And so, I think it starts there.
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  And then, throughout the process, there's the biological healing of the actual graft
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  that we put in for the reconstruction.
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  I usually tell patients that around three months or so, we're
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  expecting the graft to be pretty much healed at that point, any meniscus
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  injuries to be healed at that point.
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  The range of motion around that time should be pretty close back to normal.
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  And then, what we have for the rest of the rehab is getting the strength back, and
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  that's what takes the longest to get back.
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  And it's the same for everyone, even the professional athletes in the NFL that
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  have every resource available to them, they have physical therapists that work
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  with them every day, they have a chef that's cooking their meals, even those
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  patients, it still takes them the same amount of time to get back to sports.
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  And it really just comes down to there's no cheat code of getting that muscle back
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  other than just putting in the hard work.
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  And so, as patients get back to playing, I think that we see re-injuries—if
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  we see someone with an ACL injury in the first place, we know that they're
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  playing at a level, they're cutting, they're pivoting, they're doing something
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  at a high energy level that has the propensity to cause an ACL injury.
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  And so, those athletes, when they go back to playing the same sport with the same
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  amount of energy that they played with to begin with, they're just inherently
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  at risk of also either re-tearing the same knee or injuring the other knee.
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  And I've seen that in my practice, not necessarily as much on the same
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  knee, but on the other knee, of having a patient tear their ACL,
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  say, on their left knee, and then, you know, a year later or eighteen
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  months later, injuring the other side.
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  And when that happens, we start to look for some other things of why would this
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  be happening as far as their posterior tibial slope is the alignment of their
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  leg in such a way that puts them at risk, if their knee is valgusing, for example.
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  Especially in female athletes, we look at the the biofeedback
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  of landing from a jump.
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  A lot of women will have their knees sort of buckle in or go knock-kneed.
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  And so, recognizing that and trying to correct those things with biofeedback is
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  where our physical therapists come in to help try to learn different ways to land
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  with our knees, to put us in positions that don't put the ACL at risk of tearing.
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  And then, there's been a lot of studies that look at other things that
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  increase the risk of ACL injuries, even concussions for some reason.
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  They're not exactly sure the direct correlation with that, but patients
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  that have concussions are at higher risk of tearing their ACLs.
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  There's just so much interesting connections to athletes that are
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  playing these high-level sports and putting so much energy through
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  their knees and playing physically.
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  There's so many different connections to an ACL injury, and it's really interesting
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  to learn about those things, because it helps us in the prevention department
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  of trying to prevent these injuries from happening in the first place.
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  Melanie Cole, MS: Yeah, that's so important.
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  You made so many great points, and that's interesting about concussion and ACL risk.
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  You know, we know females have that higher risk of ACL injury, but concussion, that's
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  an interesting field of study right there.
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  So Dr.
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  Reside, as we get ready to wrap up, when you think about patients, whether they are
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  collegiate, professional, or even weekend warriors, you know, when we think about
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  cross-training and chronic overuse, not so much acute injuries as we're talking about
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  here today, what would you like patients to ask their surgeon or physical therapist
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  before returning back to normal activity?
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  And since readiness is really not about always what an athlete can demonstrate,
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  but how long it's been since surgery and what they are really ready for,
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  if you could leave them with one piece of advice about returning to sport
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  after an injury, what would that be?
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  Dr. Joshua Reside:
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  I think when you're thinking about going back to playing sports, there's
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  sort of three phases of that, right?
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  You have your physical readiness, you have the biological readiness,
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  you know, is everything healed?
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  And you have the psychological component to, am I ready to go back and play
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  and commit to doing those moves that I used to do in my sport that maybe
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  have ultimately led to your injury.
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  And so, I think for the biological component, that's where the
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  timeline comes in as far as just how far out after sports.
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  And there's been some pretty good studies that have shown that around
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  a nine-month mark is a good benchmark as far as having, like, a minimum.
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  And so, there's a pretty good study that showed that patients that
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  return to sports before nine months had a higher re-injury rate to the
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  same knee as far as a graft risk.
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  And so, I think at least having those nine months to really work
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  hard on the rehab is important.
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  I think the second phase of that is the physical readiness.
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  And so, that's not only getting the strength back in your quadriceps
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  muscle, but looking at the symmetry of the leg compared to the other side.
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  And so, we usually will get a Biodex test.
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  And what that does is it compares the strength in the uninjured leg and compares
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  it to the surgically reconstructed leg.
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  And what we like to see with that is a less than 10% symmetry deficit.
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  And so, we want that strength to come all the way back to at least within 10%
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  of the other leg that wasn't injured.
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  And what that does is the quadriceps muscle is so dynamic
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  that it protects the graft.
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  And so when you're running, when you're landing, when you're jumping, your
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  quadriceps muscle is doing a lot of the work as far as absorbing that energy.
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  And if you're weak in the quadriceps muscle and it's not like the other side,
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  you may be putting the graft at risk.
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  And so, I think at least, you know, waiting around nine months or so for
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  the biological healing of everything, I think getting the quadriceps
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  strength back and the limb symmetry.
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  And then, like I said before, as far as that psychological readiness,
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  that's sort of a multifaceted approach between the physical therapist,
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  between me as the surgeon, between their athletic trainer and the athlete
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  really coming together as a team and deciding are we ready to go back.
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  And what that looks like necessarily isn't just, okay, we're clear to go
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  back, and we're right back in the game.
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  What a clearance back to sports looks like is, you know, you get back to doing
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  individual drills on the sidelines where we're controlling for all the variables.
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  You don't have anybody else that's coming at your leg or trying
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  to take the ball away from you.
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  We're not running on wet grass.
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  You know, we're trying to control those unknown variables to try to be in a very
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  controlled setting to do those things.
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  Then, we sort of graduate on to practices without contact.
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  Then, we graduate on to practice with contact.
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  So, even a clearance back to playing and getting back to doing those
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  things may take several months before you're getting back to actually
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  playing at the same competition level.
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  And for some of my athletes, they do get back to returning
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  at the same performance level.
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  But sometimes that can take even up to a year to get that confidence back, to
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  get the strength all the way back and to really feel like you're getting back
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  to doing what you love to do at the same level that you were previously.
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  Melanie Cole, MS: What a great episode this was.
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  What a great discussion.
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  Dr.
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  Reside, thank you so much for joining us today and sharing your incredible
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  expertise in this really hot topic that is so interesting for all the people
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  that are involved with these athletes, whether it's a coach or a parent or
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  the athletic trainers, the physical therapists, and the orthopedic surgeons.
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  You've really given us a lot to think about, so thank you so much.
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  And to learn more about this and other healthcare topics at UF
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  Health Shands Hospital, please visit innovation.ufhealth.org.
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  And to listen to more podcasts from our experts, you can
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  visit ufhealth.org/medmatters.
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  That concludes today's episode of UF Health MedEd Cast with
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  UF Health Shands Hospital.
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  I'm Melanie Cole.