The Athlete’s Hip: Simplifying Evaluation, Treatment, and Return to Sport

The Athlete’s Hip can be a complicated issue for sports medicine professionals and athletes alike… Do you want to learn how to accurately and efficiently evaluate and treat this population?

Currently scheduling for 2018/19, see below for information regarding the course and learn if you want to host a course!

Description:

Hip pathology is an often under-appreciated and misunderstood problem for clinicians and athletes alike. As intra-articular and extra-articular hip pain has become more prominent, surgical procedures have increased exponentially, but examination and conservative management have unfortunately lagged behind.

This two-day course will delve into evidence-based evaluation, conservative management, and return to sport of athletes presenting with hip pain. Through lecture and lab sessions, you will learn how to evaluate and treat athletes presenting with intra-articular (femoroacetabular impingement syndrome, acetabular labral pathology, and ligamentum teres pathology) and extra-articular pathology (sacroiliac joint, extra-articular impingement, athletic pubalgia, piriformis syndrome, proximal hamstring pathology, and greater trochanteric pain syndrome).

By simplifying the evaluation and management of these conditions, at the conclusion of this course, clinician will be more confident in determining underlying pathology, appropriate management, need for surgical consult, and safe return to sport.

Presenter:

John Snyder, PT, DPT, OCS, CSCS

Objectives:

Upon completion of this course, participants will be able to:

  • Understand the complexity of pain and its impact on hip pathology
  • Understand the impact of femoroacetabular biomechanics on hip and concomitant LE pathology and injury risk
  • Be able to accurately assess for red flags (avascular necrosis, femoral stress fracture, and inguinal hernia) and referral from proximal regions
  • Be able to accurately and efficiently evaluate extra-articular and intra-articular hip pathology
  • Be able to screen for and determine the need for surgical intervention
  • Understand pathology dependent and region dependent manual therapy and exercise progression for hip pathology
  • Progression of LE exercise and end-stage rehabilitation principles
  • Be able to determine psychosocial, functional testing, and pathology specific factors to determine safe and efficient return to sport

Schedule

Day 1

09:00 – 09:30 Introduction & Pain Science
09:30 – 10:15 Impact of hip pathology and biomechanics on movement
10:15 – 11:00 Screening of Pelvic/Hip Region (Lab/Lecture)
11:00 – 11:15 Break
11:15 – 12:15 Examination of Intra-articular Pathology (Lecture)
12:30 – 13:30 Lunch
13:30 – 14:30 Examination of Intra-articular Pathology (Lab)
14:30 – 15:15 Examination of Extra-articular Pathology (Lecture)
15:15 – 15:30 Break
15:30 – 16:00 Examination of Extra-articular Pathology (Lab)
16:00 – 17:00 Where does surgery fit in?

Day 2

09:00 – 10:00 Epidemiology of Conservative and Surgical Interventions
10:00 – 10:45 Treatment of Intra-articular hip pathology (Lab/Lecture)
10:45 – 11:00 Break
11:00 – 12:00 Treatment of Extra-articular hip pathology (Lab/Lecture)
12:00 – 13:00 Lunch
13:00 – 14:00 End-stage Rehabilitation Considerations
14:00 – 15:30 Return to Sport Determination (Lecture/Lab)
15:30 – 15:45 Final Comments/Conclusion

Scheduled Dates

I am currently scheduling for 2018-2019. Please contact me if you are interested in hosting The Athlete’s Hip or Management of the Ice Hockey Athlete at your facility.

Hip Pain: Return to Sport Considerations

Pre-arthritic hip pain is a common occurrence among athletes, especially those competing in ice hockey1 and field-based team sports (soccer, rugby, and football).2 While this area receives less attention than knee or shoulder injuries, current research is beginning to improve diagnosis and treatment of both intra-articular and extra-articular hip pathology. But, what about return to sport?

What the Literature Says

Determining an athlete’s readiness to return to sport is complicated. The decision with regards to hip pathology is even more convoluted due to the lack of evidence. Most literature discusses outcomes following arthroscopic surgery, and only a few studies outline the proposed benefit of conservative management.3

The available literature suggests that surgery for femoroacetabular impingement is beneficial in a symptomatic population, with 87% of patients returning to sport and 82% returning to previous level of competition.4 On the other hand, no randomized controlled studies adequately compare conservative and surgical management.5 Unfortunately, at this point the research tends to relate only to reported patient satisfaction, subjective questionnaires, and self-reported return to sport.6

How Do We Determine Return to Sport?

Unlike ACL reconstruction, hip injury lacks sufficient evidence to support return to sport guidelines. According to the 2016 Consensus Statement on Return to Sport, clinicians should combine information from a biological, psychological, and social standpoint.7 These factors include:

  • Health risk based on the athlete’s specific injury (subjective and objective measures)
  • Activity risk of returning to sport (type of sport, competition level, etc.)
  • Risk tolerance (pressure, fear of re-injury, etc.)

The StAART Framework (pictured below) proposed by Shrier and colleagues sums up this approach.8 It allows the clinician to comprehend and address all areas impacted by an individual’s readiness to return to sport.

MC020-205 Starrt Framework Chart_v03

Functional Testing Considerations

A recent systematic review conducted by Kivlan and colleagues demonstrated that several tests are reliable and valid when determining return to sport after hip injuries:9

  • Single-leg Stance
  • Deep Squat
  • Single-leg Squat
  • Star Excursion Balance Test (SEBT) / Y-Balance Test

These tests have appropriate validity and reliability but no solid cut-points, so findings should be interpreted on a patient-specific basis by considering their limb symmetry index during these tasks. Significant increase in medial–lateral sway and worse anterior–posterior control during a dynamic single-leg squat task in individuals with pre-arthric hip pain supports the use of a single-leg squat assessment.10

The modified star excursion balance test (also known as the Lower Quarter Y-Balance Test)  has been successful in identifying asymmetry and impaired proximal stability in many conditions. Recently, Johansson and colleagues performed the first study to determine the criterion and divergent validity of the SEBT in individuals with femoroacetabular impingement11. They determined that SEBT performance in the posterolateral and posteromedial directions had high to moderate criterion validity in relation to the HAGOS subscales for pain intensity and symptoms. Additionally, the posterolateral direction and ADL function showed high to moderate criterion validity. Finally and most importantly, the SEBT showed adequate divergent validity and could successfully differentiate between healthy individuals and individuals diagnosed with FAI.

Several recent studies have investigated if hop testing is appropriate in this population. Kivlan and colleagues evaluated the difference in hop testing (cross-over reach test, medial triple hop test, lateral triple hop test, and cross-over hop test) between the involved and uninvolved hip in dancers with hip pathology.12 All tests demonstrated excellent reliability (0.89 – 0.96); however, only the medial triple hop test showed significant difference between the two limbs with the non-involved limb achieving 17.8 cm more distance than the involved limb.

More recently, Kivlan and colleagues investigated the hop performance between dancers with clinically diagnosed femoroacetabular impingement and an asymptomatic control group. This study found a significant difference of approximately 50 cm when comparing the performance of the FAI group to the asymptomatic control group during both the medial triple hop test and the lateral triple hop test:13

table-remake

Further supporting the use of hop and dynamic balance activities, findings from another recent study determined that following arthroscopic hip surgery and concomitant rehabilitation, patients demonstrated > 90% limb symmetry index in the performance of a single-leg squat test, single-leg vertical jump, single-leg hop for distance, and single-leg side hop.14 While this information shows that we can achieve a LSI that is often used in return to sport of athletes post-ACL reconstruction, functional testing should be used with caution when translating it to a population of athletes with hip pain.

Continue with Caution

In the absence of definitive return to sport criteria, the clinician must focus on the tissue health (the load the tissue can absorb before injury), individual tissue stresses imposed by the athlete’s chosen sport and competition level, and any pertinent psychosocial factors (fear of re-injury).

Return to sport testing should be considered with caution as little evidence is available for this patient population.

References:

1. Lerebours F, Robertson W, Neri B, Schulz B, Youm T, Limpisvasti O. Prevalence of Cam-Type Morphology in Elite Ice Hockey Players. Am J Sports Med. 2016 Jan 28. pii: 0363546515624671. [Epub ahead of print]

2. Gerhardt MB, Romero AA, Silvers HJ, Harris DJ, Watanabe D, Mandelbaum BR. The Prevalence of Radiographic Hip Abnormalities in Elite Soccer Players. American Journal of Sports Medicine. 2012;40(3):584-588. doi:10.1177/0363546511432711.

3. Wall PD, Fernandez M, Griffin D, Foster N. Nonoperative Treatment for Femoroacetabular Impingement: A Systematic Review of the Literature. PMRJ. March 2013:1-9. doi:10.1016/j.pmrj.2013.02.005.

4. Casartelli NC, Leunig M, Maffiuletti NA, Bizzini M. Return to sport after hip surgery for femoroacetabular impingement: a systematic review. British Journal of Sports Medicine. 2015;49(12):819-824. doi:10.1136/bjsports-2014-094414.

5. Reiman MP, Thorborg K, Hölmich P. Femoroacetabular Impingement Surgery Is on the Rise—But What Is the Next Step? Journal of Orthopaedic & Sports Physical Therapy. 2016;46(6):406-408. doi:10.2519/jospt.2016.0605.

6. Sim Y, Horner NS, de SA D, Simunovic N, Karlsson J, Ayeni OR. Reporting of non-hip score outcomes following femoroacetabular impingement surgery: a systematic review. J Hip Preserv Surg. 2015;2(3):224-241. doi:10.1093/jhps/hnv048.

7. Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine. May 2016. doi:10.1136/bjsports-2016-096278.

8. Shrier I. Strategic Assessment of Risk and Risk Tolerance (StARRT) framework for return-to-play decision-making. British Journal of Sports Medicine. 2015; 49: 1311–15.

9. Kivlan BR, Martin RL. Functional Performance Testing of the Hip in Athletes: A Systematic Review for Reliability and Validity. International Journal of Sports Physical Therapy. 2012;7(4):402-412.

10. Freke MD, Kemp J, svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular impingement: a systematic review of the evidence. British Journal of Sports Medicine. June 2016. doi:10.1136/bjsports-2016-096152.

11. Johnansson AC, et al. The Star Excursion Balance Test: Criterion and divergent validity on patients with femoral acetabular impingement. Manual Therapy. 2016; 26(C): 104-109. doi:10.1016/j.math.2016.07.015.

12. Kivlan BR, Carcia CR, Clemente FR, Phelps AL, Martin RL. Reliability and validity of functional performance tests in dancers with hip dysfunction. International Journal of Sports Physical Therapy. 2013 Aug;8(4):360-9.

13. Kivlan BR, et al. Comparison of Range of Motion, Strength, and Hop Test Performance of dancers with and without a Clinical Diagnosis of Femoroacetabular Impingement. International Journal of Sports Physical Therapy. 2016; 11(4): 527-535.

14. Tijssen M, van Cingel R, de Visser E, Sanden der MN-V. A clinical observational study on patient-reported outcomes, hip functional performance and return to sports activities in hip arthroscopy patients. Physical Therapy in Sport. 2016;20(C):45-55. doi:10.1016/j.ptsp.2015.12.004.

Learn from John: Upcoming Courses

I will be teaching two one-day continuing education courses in Indiana later this month through Medical Minds in Motion. These courses will teach clinicians (PT, PTA, or OT) evidence-based assessment, treatment, and return to sport/recreation of hip pathology.

For more information, see the below links for specific details of each course or feel free to message me directly.

February 27th – Indianapolis, Indiana – Evidence-Based Assessment and Treatment of the Hip Joint

February 28th – Evansville, Indiana – Evidence-Based Assessment and Treatment of the Hip Joint

Thanks!

John Snyder, PT, DPT, CSCS

What Are We Missing? The Influence of Fatigue.

The following is another article written for the online, video-based physical therapy continuing education company MedBridge

Recently, a lot of attention has been paid to re-injury and return to sport following anterior cruciate ligament reconstruction (ACLR) and the results continue to be less than exceptional. A recent case series of elite collegiate athletes who suffered ACL injuries prior to and during their college careers continually found difficulty returning to sports participation (Kamath et al., 2014). Of the 35 athletes who had undergone ACLR prior to enrollment in college, the rate of re-operation on the involved limb was 51.4%, the rate of re-rupture of the ACL graft was 17.4%, and contralateral ACL rupture was 20.0% within this population of athletes. Similarly, those who underwent ACLR during college had a 20.4% re-operation rate, 1.9% suffered re-rupture of the ACL graft, and 11.1% of these athletes underwent ACLR on the contralateral limb. In agreement with these findings, a prospective cohort study of 456 collegiate athletes conducted by Rugg and colleagues found that athletes entering college with a history of ACLR had a 892.9-fold increase in knee surgery compared to those who entered college without undergoing surgery. Unfortunately, these findings are not isolated to collegiate athletes as professional (Busfield et al., 2009) and high school athletes (McCullough et al., 2012) alike have similar statistics. Considering these numbers, it points to inadequate or premature return to athletic participation, which may be because we are overlooking a very important aspect of athletic competition.

First, let’s look at what factors have been shown to predispose these athletes to injury. Hewett et al conducted a prospective cohort study that identified factors that may put athletes at risk for initial ACL injury. After screening 205 female collegiate athletes with a drop-jump task, 9 athletes went on to suffer an ACL injury during the following season. These 9 athletes had several important factors in common in comparison to those who did not go on to suffer injury. Knee abduction angle at landing was 8° greater, knee abduction moment was 2.5 times greater, and there was a 20% higher ground reaction force in ACL–injured than in uninjured athletes. More importantly, the authors determined that injury could be predicted in those with an increased knee abduction moment (dynamic valgus) with 73% specificity and 78% sensitivity.

Prior to return to sport, many athletes will undergo functional testing (hop testing, Y-Balance Test, etc.), but do these tests, done under optimal circumstances, tell the full story or are we missing something?

Fatigue has been shown repeatedly to have negative affects on lower extremity biomechanics. A systematic review recently examined the literature pertaining to lower extremity biomechanics and neuromuscular fatigue during single-leg landings (Santamaria et al., 2010). After analyzing 8 studies and 141 total subjects, kinematic data revealed greater knee and hip flexion and increased dorsiflexion post-fatigue. More importantly, following the introduction of fatigue, there was no change in peak knee valgus angles. However, as anticipated/practiced drop-landings are performed primarily in the sagittal plane, these specific procedures may not be sufficient to determine movement patterns during athletic competition. When an unanticipated landing was used, the results were drastically different with a significant increase in peak knee valgus angle post-fatigue compared to pre-fatigue. This unanticipated landing would seem to represent the demands of athletic competition more accurately and thus demonstrates an increased risk of injury with neuromuscular fatigue. In agreement with these findings, Brazen et al found no change in frontal plane biomechanics during an anticipated drop-landing task after neuromuscular fatigue, however they did find a higher anterior-posterior time to stabilization (TTS) and vertical TTS, which once more increases the likelihood of injury.

More specific to patients following ACLR, Webster et al conducted a study comparing the response to neuromuscular fatigue between uninjured control subjects and athletes following ACLR. This study once again utilized an anticipated drop-landing task with data collected pre and post fatigue. Fatigue led to reduced flexion in the lower limb, increased hip and knee abduction, increased knee rotation, and reduced knee joint moments. The response to fatigue was similar with no significant differences between the ACL-reconstructed limb and the control group as well as the reconstructed limb and the contralateral limb. To further investigate the lower extremity biomechanics of athletes following ACLR, the Lower Extremity Error Scoring System (LESS) was developed. Padua et al determined the LESS to be a valid and reliable tool in assessing jump-landing biomechanics with good inter-rater reliability (ICC= 0.84) and excellent intra-rater reliability (ICC= 0.91). This evaluation tool involves counting the number of faulty movement patterns during a jump-landing task with < 4 errors being an excellent score, ≤ 5 being good, ≤ 6 being moderate, and > 6 being poor landing mechanics. When evaluating the influence of fatigue on LESS scores, Gokeler et al found significant differences between patients status-post ACLR and uninjured control subjects. The initial median score pre-fatigue for ACLR patients was 6.5 (poor) and 7.0 following fatigue, whereas the uninjured control subjects scored 2.5 (excellent) pre-fatigue and drastically increased to 6.0 (poor) post-fatigue. This shows an obvious decline in movement quality following fatigue, which may place both post-ACLR patients and uninjured controls at risk for injury.

Fatigue is an often-neglected aspect in the decision to return an athlete to sport or to assess an athlete’s initial risk for injury. This data should be used to further evolve our testing procedures to account for these potentially injurious movement patterns secondary to neuromuscular fatigue. Trent Nessler, DPT developed a fatigue protocol and concomitant testing procedure for return to sport and injury risk assessment purposes as part his Dynamic Movement Assessment. Albert Einstein was quoted saying, “The definition of insanity is to continually do the same thing over and over expecting a different result”. If we are to improve these return to sport and re-injury numbers, fatigue cannot be overlooked anymore and must be included in our clinical decision making process.

When Can I Play Again? Return to Sports Testing for the Upper Extremity.

The following is another article written for the online, video-based physical therapy continuing education company MedBridge

A lot has been written and researched with regards to return to sport criteria and testing for injuries of the lower extremity, and more specifically following anterior cruciate ligament reconstruction (ACL-R), however little attention has been given to injuries of the upper extremity. As with ACL-R, return to sport following surgical intervention in the upper extremity is less than stellar. Harris et al conducted a systematic review that found amongst elite pitchers undergoing shoulder surgery (rotator cuff, biceps/labrum, instability, internal impingement, ect.), only 68% returned to play 12 months following surgery. Additionally, they found that 22% of major league baseball pitchers included in their review never returned to sport. In agreement with these findings, Cohen et al evaluated the return to sport of professional baseball players following shoulder and/or elbow surgery and found only 48%  of participants returned to the same or higher level of professional baseball following surgery. Why are these numbers so low and what can we do as rehabilitation specialists to improve the rate of return to sport following surgery?

Sometimes, it simply takes correctly identifying those who are at risk of re-injury or those simply not ready to rerun to their chosen sport. When devising an appropriate return to sport test, Phil Plisky, PT, DSc, OCS, ATC, CSCS says in his course, “Return to Sport and Discharge Testing“, that each test should be reliable, predictive of injury, have discriminate validity, and the test must be modifiable with training/rehabilitation. With regards to the upper extremity, there is a significant gap in knowledge/research in comparison to the lower extremity. That being said, the Y-Balance Test has recently been adapted to help fill this gap. Gorman et al investigated to reliability of the Upper Quarter Y Balance Test (UQ-YBT) and found that the test-retest reliability (0.80-0.99) and inter-rater reliability (1.00) ranged from good to excellent. Along with this information, normative data was determined amongst active adults with males generally performing the test superiorly to females and a minimally detectable difference of 8.1 cm in the medial direction, 6.4 cm in the superolateral direction, and 6.1 cm in the inferolateral direction. In addition to these findings, Westrick et al found that there was no significant difference between the dominant and non-dominant limb when young females or males perform the UQ-YBT. This shows that, generally speaking, any significantly asymmetrical findings should be investigated further prior to returning the athlete to his/her sport. While, currently, there are no studies investigating this test’s capacity to predict injury or its ability to be modified with training, the excellent reliability and discriminate validity make this a solid return to sport test.

Similarly, the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) offers an additional way to assess upper extremity dynamic stability, albeit in a singular plane. Once again, this test demonstrates excellent reliability with a Test-Retest Reliability of 0.92 (Goldbeck et al), an intersession reliability ranging between 0.87 to 0.96 (Tucci et al), and an intrasession reliability ranging between 0.86 and o.97. Furthermore, Tucci et al also found the CKCUEST to have discriminate validity as those performing the test with diagnosed subacromial impingement performed significantly inferiorly in comparison to asymptomatic participants. Along with this excellent reliability and obvious display of closed kinetic chain dynamic stability, the CKCUEST also has recently been shown to have the capacity to predict injury. Pontillo et al performed a prospective cohort study attempting to identify potentially factors that would be predictive of upper extremity injury in collegiate football players. The only significant factor in predicting future injury in this population of athletes was a CKCUEST in which the athlete completed < 21 touches (Sn= 79%, Sp= 83%, + LR= 4.74, – LR= 0.25, Odds Ratio= 18.75). This is a significant finding and shows the benefit for utilizing this test not only for return to sport, but also in pre-season testing to identify individuals who are at risk for injury.

For a more demanding task, similar to the single-leg hop testing utilized for patients following ACL reconstruction, the One-Arm Hop Test was created to test the athlete’s plyometric, power, and dynamic closed kinetic chain stability. Unfortunately, to this date, there has only been one study investigating this specific return to sport test. Falsone et al found the test to have good Test-Retest Reliability (0.78-0.81) and also found only a 4.4% difference between non-dominant and dominant limbs when performing the test. This once again shows the ability to assess post-operative function based upon the symmetry between limbs. While this may not be a perfect solution, it allows the ability to utilize the test with evidence-based backing until further research is conducted investigating its ability to predict injury and/or be modified with training.

Returning an athlete to sport is a multi-factorial decision that must incorporate that athlete’s psychological readiness to return to play, strength, range of motion, pain level, and ultimately the ability to perform the movement patterns consistent with their sport and/or position. The aforementioned return to sport tests provides a hierarchical (i.e. increasingly demanding) system for testing the individual’s capacity to withstand the rigors of their chosen activity. This allows clinicians something outside of subjective reports, range of motion, and strength measures to assess your patient’s ability to perform dynamic upper extremity tasks prior to returning to sport and in doing so, we may be able to identify some of the deficits our athletes are hiding that are preventing them from ultimately returning to their sport.

The Psychology of Return to Sport

Biomechanical and neuromuscular factors receive considerable attention in discussing Return to Sport Following ACL Reconstruction. Psychological considerations, however, despite playing an integral role in returning an injured athlete to their respective sport, often go under-appreciated. The purpose of this piece is therefore to briefly review the literature related to the psychology of ACL injury and surgery, and to discuss how the rehabilitation professional can enhance their understanding of the psychological domain to foster improved outcomes in working with this population of athletes.

Once a patient has successfully met all return to sport criteria, the next step naturally involves returning to sport. While some patients seamlessly return to their pre-injury status, others struggle with simply returning to their sport. One needs to look no further than the case of Derrek Rose, star of the Chicago Bulls and MVP of the NBA in 2011, to appreciate the challenge in returning an athlete to sport. After sustaining an ACL tear and subsequently undergoing surgery, he was sidelined for approximately 16 months. In contrast to this situation, Adrian Peterson, defied all odds by returning to the starting lineup nine months following his surgery. While both of these athletes undoubtedly worked hard throughout the rehabilitation process, other factors may account for the difference in time in returning to their respective sports.

According to a recent systematic review conducted by Te Wierike et al.,fear of re-injury was the leading cause of failure for athletes with an ACL injury and subsequent reconstruction to return to sport. Along these same lines, Ardern et al conducted a systematic review with meta-analysis of return to sport outcomes of nearly 5,000 patients following ACL reconstruction. This study demonstrated that only 63% of patients returned to their pre-injury level of competition. Again, fear of re-injury was the most common reason cited for a reduction in or cessation of sports participation. In agreement with the aforementioned studies, a case-control investigation conducted by Ardern et al, found that significant independent contributions for returning to pre-injury level one year post-operatively were explained by psychological factors. These included subjective readiness to return to sport, fear of re-injury, and sport locus of control. This study also determined that factors influencing athletes’ prospective judgment of their ability to return to sport predicted returning to their pre-injury level.

A cross-sectional study performed by Chmielewski et al found that fear of movement/re-injury levels appear to decrease during ACL reconstruction rehabilitation and are associated with function in the timeframe when patients return to sports. Therefore, being psychologically prepared for return to sport is critical when considering each patient’s readiness. In addition to this study, Ardern et al conducted a systematic review looking into the psychological factors involved in returning athletes to sport following injury. This review of 11 studies and nearly 1,000 patients determined that the three central elements of return to sport were from the self-determination theory, which includes: autonomy (urge to be causal agents of one’s own life and act in harmony with one’s integrated self); competence (seek to control the outcome and experience mastery); and relatedness (universal want to interact). This same study found that positive psychological responses including motivation, confidence, and low fear were associated with an increased likelihood of returning to one’s pre-injury level status in a more timely manner.  Naturally, return to sport elicits a certain level of fear and anxiety for all athletes, though individuals who possess these internal motivating factors enjoy improved post-operative outcomes.

Considering this information, the question becomes how can clinicians identify those patients who may be at a psychological disadvantage during the rehabilitation process? According to Chmielewski et al, a patient’s psychosocial profile can be positively altered in the short-term following ACL reconstruction. This means that clinicians must take the time to accurately identify those individuals who may be at risk of poor outcomes due to fear of re-injury or fear avoidance beliefs. This can be accomplished through the use of the Tampa Scale for Kinesiophobia (TSK-11), the Fear Avoidance Beliefs Questionnaire (FABQ), and/or the more specific Injury-Psychological Readiness to Return to Sport (I-PRRS) Scale. Recently, Lentz et al determined that individuals with a lower TSK-11 score were more likely to return to their pre-injury level of competition following ACL reconstruction. While the other two outcome measures have greater scientific backing at this point, the newer I-PRRS has just begun the process of validation. In 2009, Glazer et al published a validation study to support the scale’s utility. The I-PRRS scores were found to be lowest after injury, increased before release to practice, increased again before returning to competition, and had no change after competition. This demonstrates the general progression of psychological preparedness and thus the validity needed to make this a useful measure for clinicians when determining an athlete’s readiness for return to sport.

These outcome measures may give us the ability to more accurately identify those individuals at risk for suboptimal outcomes. Regardless of baseline mentality, however, recovery from injury demands a psychologically driven process. This Biopsychosocial Model is composed of 4 distinct processes (Wiese-Bjornstal et al). The first of which is Cognition, which includes the thoughts an athlete experiences following injury. Within this category lies the athlete’s internal Health Locus of Control (HLOC), which is the capacity that the athlete believes they control the events in their life. Nyland et al found that athletes with a high internal HLOC were more satisfied with their knee function in addition to their ability to perform ADLs, and participate in sport following ACL reconstruction. The second category is the patient’s Affect.  BioPsySoc-InjThis concerns the way an athlete feels following injury. As most clinicians appreciate, injuries can lead to substantial psychological changes, sometimes verging on depression. Studies have shown, however, that there are positive psychological changes as rehabilitation progresses, with fewer negative emotions and more positive feelings about returning to sport. In light of this information, the fear of re-injury has significant impact on the rehabilitation process and can lead to sub-optimal outcomes, potentially preventing return to athletics. The Behavior of the patient throughout the rehabilitation process can also be an influential factor. The two most important behaviors for patients following ACL reconstruction are avoidance coping and rehabilitation adherence. Avoidance coping can be broken into behavioral avoidance coping (the conscience decision to remove oneself from a threatening environment) and cognitive avoidance coping (the responses aimed at denying or minimizing the seriousness of a crisis). While these avoidance techniques may be beneficial in the recovery process, poor adherence to physical therapy has been shown to be detrimental to recovery. Brewer et al found that patients who had a higher score for adherence experienced fewer knee symptoms compared to those who demonstrated poor adherence to their physical therapy program. The final cornerstone to the Biopsychosocial Model is the Outcome. A deficiency or inadequacy in any combination of the three previous categories can negatively impact a patient’s post-rehabilitation outcome. As was shown by Lentz et al, return to pre-injury level of sports participation is multi-factorial and those who did return had less knee joint effusion, fewer episodes of knee instability, lower knee pain intensity, higher quadriceps peak torque-body weight ratio, higher IKDC scores, and lower TSK-11 scores.

Finally, considering this model and the personality traits associated with successful outcomes, what can clinicians do to foster improved outcomes following ACL injury and/or surgery? Regardless of whether or not reconstruction is performed following ACL injury, several psychological interventions have been proven beneficial for athletes during their rehabilitation (relaxation, imagery, training of self-efficacy, and modeling). Cupal and Brewer conducted a randomized controlled trial comparing the outcomes of patients who received relaxation and guided imagery training in conjunction with a typical post-operative protocol to those who only completed the protocol. In the end, the experimental group had greater knee strength, less re-injury anxiety, and less pain compared with the placebo and control group. In order to improve patients’ self-efficacy through modeling, Maddison et al gave their intervention group two separate videos to aid the ability of their athletes’ to cope throughout the rehab process. This study showed that patients, who watched the videos, perceived less pain and had more self-efficacy than those who did not receive this intervention. It should also be noted that athletes often benefit from discussing their injury (i.e. how it happened and how it has affected their life). Additionally, Mankad et al found that athletes who wrote about their injury in the form of written disclosure statements had a reduction of stress and total mood disturbances.

Returning an athlete to sport requires the use of a specific criterion-based protocol, functional sport-specific testing, and proper psychological management of stressors and emotions associated with the injury.  Successful rehabilitation of an athlete back to their sport involves careful consideration of all of these aspects. Considerable attention has been paid to the pathoanatomical, biomechanical, and neuromuscular aspects though sports medicine professionals often neglect the psychological impact. As the recognition and implementation of psychologically-driven interventions increases, positive outcomes with regards to return to sport should follow.