Abstract
Background:
While return to sport (RTS) in young athletes after anterior cruciate ligament (ACL) reconstruction has been well studied, little is known regarding their rate of RTS after multiligament knee injury (MLKI).
Purpose:
To assess the level of and factors associated with RTS after MLKI in young athletes.
Study Design:
Case series; Level of evidence, 4.
Methods:
We retrospectively identified 116 patients aged ≤23 years who had sustained an injury to ≥2 knee ligaments and undergone operative reconstruction or repair of ≥1 ligament. Our primary outcome was self-reported RTS at the preinjury level or higher. We estimated the likelihood of RTS using binomial logistic regression. Secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL–Return to Sport after Injury (ACL-RSI), and 12-Item Short Form Health Survey (SF-12) physical and mental health summaries.
Results:
A total of 30 (25.9%) patients (24 men, 6 women; mean age, 18.1 ± 2.5 years) completed patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]). A total of 28 patients underwent surgical treatment of ≥2 ligaments. RTS was achieved by 90% of patients, and 43.3% returned to their preinjury level or higher. Patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (odds ratio [OR], 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017). Patients who achieved RTS at their preinjury level or higher had significantly higher IKDC-SF and ACL-RSI scores versus patients who did not (P = .001 and P = .002, respectively). The number of ligaments injured, age, mental health diagnosis, and SF-12 scores were not associated with the ability to RTS at the preinjury or higher levels.
Conclusion:
Most young athletes who sustained MLKI were able to return to play at some level, but a minority returned to their preinjury level. Patients who did return at preinjury or higher levels had higher IKDC-SF and ACL-RSI scores than those who did not. Performance in cutting and/or pivoting sports was negatively associated with RTS.
Keywords: ligament reconstruction, multiligament knee injury, return to sport, young athlete
Multiligament knee injuries (MLKIs) involve ≥2 ligaments of the knee that may occur secondary to high-energy mechanisms, such as motor vehicle accidents, or low-energy mechanisms, such as sports-related injuries. 6 When these injuries occur on the playing field, they profoundly affect an athlete’s ability to regain knee function and return to their level of athletic performance before injury. 13 The current literature, 2,4,17,19,22 while limited, has investigated return to sport (RTS) rates after MLKI in professional athletes, demonstrating RTS of up to 88.2%. However, there is little research on RTS after MLKI specifically in high school– and collegiate-age athletes.
RTS after isolated anterior cruciate ligament (ACL) tears has been widely studied in young athletes, demonstrating a high overall RTS rate but at varying levels. 9 –12,14,15,20,22 With the continued evolution of ACL reconstruction (ACLR) and optimized postoperative ACL rehabilitation protocols, RTS rates after ACLR continue to improve but remain imperfect. 18 When counseling young athletes on their return to athletics after MLKI, most recommendations are either anecdotal or extrapolated from the ACLR literature.
The purpose of this study was to evaluate the rate and level of RTS in high school– and collegiate-age athletes after MLKI reconstruction. Second, we aimed to identify the association of factors associated with successful RTS (ie, return to preinjury level or higher). We hypothesized that there would be a favorable overall RTS rate in this age group, similar to those undergoing ACLR, but that <50% would be able to return to the level played before injury at a minimum of 1 year postoperatively.
Methods
This study was approved by the institutional review board at our institution. The study inclusion criteria were as follows: age ≤23 years at the time of injury, as we determined this to be the upper limit of collegiate-age patients; competed at any level of sport at the time of primary injury; sustained an injury of ≥2 knee ligaments; underwent operative reconstruction or repair of ≥1 ligament; and had ≥1 year of documented follow-up. We defined MLKI as an injury involving ≥2 of the following ligaments: ACL, posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), or posterolateral corner (PLC). Concurrent injuries to the LCL and PLC were considered a single ligament injury. The exclusion criteria were as follows: age >23 at the time of injury; any underlying musculoskeletal disorder; and a history of prior surgery to the affected extremity. Eligible patients were retrospectively identified in the electronic medical record of our level 1 tertiary referral center by the Current Procedural Terminology code and then by age at the time of injury. Patients were first contacted via mail and then completed patient-reported outcome surveys over the telephone if willing to participate. We attempted to contact patients a minimum of 3 times via telephone and, if unable to be reached, voicemails were left. This is a similar process to a previous study evaluating RTS after ACLR. 16
Patient age, preinjury level of sports, number of ligaments injured, involvement in a cutting sport, and a concomitant mental health diagnosis (ie, depression, anxiety) were recorded. The level of sport was based on patients’ self-reported sports involvement at the time of injury. The primary outcome variable was patients’ self-reported ability to play their primary sport postoperatively relative to preinjury performance, in which possible responses included none, significantly below, somewhat below, same, or above. The secondary variables included the 2000 International Knee Documentation Committee Subjective Knee Form (IKDC-SF), ACL–Return to Sport after Injury (ACL-RSI), 12-Item Short Form Health Survey (SF-12) physical and mental health summaries, and self-reported ability to return to preinjury activities (reported as a percentage of their preinjury ability). These validated scales evaluate pre- and postoperative knee function, mental readiness to return to activity, and general physical and mental function, respectively.
Statistical Analysis
The likelihood of RTS at the preinjury or higher level was estimated using binomial logistic regression and was reported as odds ratios (ORs) and 95% CIs. Age at injury was included as a continuous predictor variable, and preinjury level of sport was included as an ordinal categorical predictor variable (1 = recreationally/club/intramural, 2 = high school junior varsity, 3 = high school varsity, 4 = National Collegiate Athletic Association, or 5 = professional), and there were 3 binary categorical predictor variables: number of ligaments injured (2 or 3; coded as 0 or 1, respectively), whether cutting activities were involved in their sport (“no” or “yes”; coded as 0 or 1), and concurrent mental health diagnosis (“no” or “yes”; coded as 0 or 1). Independent 2-tailed t tests were performed to compare self-reported variables (self-rated percentage ability to play at a preinjury level, ACL-RSI, IKDC-SF, and SF-12 physical and mental) between patients who did and those who did not return to the preinjury level of sports or higher. The Pearson chi-square test was used to compare rates of RTS at preinjury or higher levels between patients who had concurrent ACL and MCL injuries and those who had 2- or 3-ligament injuries, including the ACL and PCL, LCL, and/or PLC. All analyses were performed using SPSS Version 28 (IBM). The threshold for statistical significance was set at P < .05.
Results
Patient Characteristics
A total of 116 patients from our MLKI registry met the inclusion criteria, of whom 30 patients completed the patient-reported outcome surveys at a mean follow-up of 7.8 years (median, 6.6 years [range, 1.1-19.5 years]) (Figure 1). All but 1 patient completed the surveys in their entirety; 1 patient declined to complete the IKDC-SF, ACL-RSI, and SF-12 questionnaires. Table 1 shows the baseline characteristics of the study patients. There were 24 men and 6 women, with a mean age of 18.1 years (range, 12-23 years). This is similar to the distribution of all patients who met the inclusion criteria, of whom 26.7% (31/116) were women.
Figure 1.
Flow diagram of patient inclusion.
Table 1.
Baseline Patient Characteristics (N = 30) a
| Variable | Value |
|---|---|
| Age at injury, y | 18.07 ± 2.532; 18 (12-23) |
| Sex, male/female, n (%) | 24 (80)/6 (20) |
| Time from surgery, mo | 94.7 ± 61.8; 80.1 (12.9-237.4) |
| Number of ligaments injured | 2.23 ± 0.430; 2.00 (2-3) |
a Data are reported as mean ± SD or median (range) unless otherwise indicated.
The characteristics of each study participant are shown in Appendix Table A1. A total of 28 patients underwent reconstruction or repair of ≥2 ligaments; in 2 patients with concurrent ACL and MCL injuries, the MCL was treated nonoperatively. Two patients with PLC injuries and 1 patient with PCL injury were treated with repair, all other operative ligaments were treated with reconstruction. Of our study population, 17% (5/30) sustained a knee dislocation based on radiographic evaluation. In this cohort, 43% (13/30) of patients were found to have no other concurrent injuries, 40% (12/30) had concurrent meniscal tears, 7% (2/30) sustained medial patellofemoral ligament tears treated with reconstruction, and 7% (2/30) of patients sustained fractures. Also, 80% of the patients (24/30) in this cohort reported that their primary sport at the time of injury involved fast cutting and/or pivoting. Last, 10% of patients were found to have a current mental health diagnosis, including major depressive disorder, anxiety, or posttraumatic stress disorder.
Return to Sport
In this cohort, the overall RTS rate at any level of sport was 90%, while 43.3% returned to their preinjury level or higher. Those who participated in cutting sports had significantly lower odds of returning at a preinjury or higher level (OR, 0.013 [95% CI, 0.000-0.461]; P = .017), while those participating in a higher level of sport before their injury (ie, professional vs recreational) were significantly more likely to return to a preinjury or higher level (OR, 3.516 [95% CI, 1.034-11.955]; P = .044) (Table 2).
Table 2.
Results of Binomial Logistic Regression Analysis for RTS at Preinjury or Higher Levels a
| Variable | OR (95% CI) | P |
|---|---|---|
| Age at injury, y | 0.644 (0.360-1.152) | .138 |
| Level of sport before injury | 3.516 (1.034-11.955) | .044 |
| Number of ligaments injured | 0.900 (0.069-11.697) | .936 |
| Cutting sport | 0.013 (0.000-0.461) | .017 |
| Mental health diagnosis | 2.881 (0.066-125.950) | .583 |
a Bold P values indicate statistical significance (P < .05). OR, odds ratio; RTS, return to sport.
Responses to patient-reported outcome surveys can be found in Tables 3 and Appendix Table A2. Participants who returned to their preinjury or higher level of sports had significantly higher self-reported percentage ability to perform normal athletic activities since injury compared with those who did not (94% ± 8.64% vs 65.94% ± 24.18%; P < .001). Additionally, those who achieved RTS at preinjury or higher levels reported significantly higher scores on the ACL-RSI (80.35 ± 16.32 vs 53.62 ± 23.09; P = .002) and the IKDC-SF (89.77 ± 10.15 vs 70.19 ± 18.2; P = .001). There was a trend toward increased RTS rates in athletes with ACL and MCL combination tears compared to those with ACL and PCL/LCL/PLC involvement. However, this finding was not statistically significant (50% vs 25%, respectively; P = .225).
Table 3.
Patient-Reported Outcome Scores Overall and According to RTS at Preinjury or Higher Levels a
| RTS at Preinjury or Higher Levels, Mean ± SD | |||||
|---|---|---|---|---|---|
| Overall, Mean ± SD (Range) |
Achieved | Did Not Achieve | P | 95% CI | |
| ACL-RSI | 64.7 ± 24.26 (13.3 to 100) |
80.35 ± 16.32 | 53.62 ± 23.09 | .002 | –42.661 to –10.785 |
| IKDC-SF | 78.3 ± 18.07 (44.8 to 100) |
89.77 ± 10.15 | 70.19 ± 18.2 | .001 | –30.481 to –8.676 |
| SF-12 physical | 51.3 ± 7.91 (25.4 to 60.6) |
54.17 ± 6.01 | 49.35 ± 8.62 | .107 | –10.752 to 1.112 |
| SF-12 mental | 52.9 ± 7.59 (31.5 to 60.8) |
55.71 ± 5.32 | 50.92 ± 8.44 | .095 | –10.460 to 0.890 |
| Ability to perform preinjury activities, % b | 77.2 ± 23.80 (10 to 100) |
94 ± 8.64 | 65.94 ± 24.18 | <.001 | –40.933 to –15.178 |
Bold P values indicate statistical significance (P < .05).
b Reported as a percentage of preinjury activity. ACL-RSI, ACL–Return to Sport after Injury; 2000 IKDC-SF, International Knee Documentation Committee Subjective Knee Form; RTS, return to sport; SF-12, 12-Item Short Form Health Survey.
Discussion
In this study, we found a 90% overall RTS rate in young athletes after MLKI, with 43.3% returning to their preinjury level of sport or higher. Furthermore, patients who had played sports at a higher level before injury were more likely to RTS at their preinjury level or higher (OR, 3.516 [95% CI, 1.034-11.955]; P = .044), while those who played cutting sports were less likely to do so (OR, 0.013 [95% CI, 0.000-0.461; P = .017) (see Table 2). Last, we demonstrated that patients who achieved RTS at preinjury or higher levels had significantly higher ACL-RSI and IKDC-SF scores compared with patients who did not (P = .002 and P = .001, respectively).
Our rate of RTS differs from the reported 64% RTS rate described by Bakshi et al 2 in their study of 50 National Football League (NFL) athletes. The difference in RTS rates between their study and ours is likely due to the higher demand required of NFL athletes’ knee function compared with amateur athletes and the longer follow-up period in our study. In contrast, Borque et al, 4 in their 2022 retrospective review of 136 elite athletes, reported that 88.2% of athletes in their cohort who underwent MLKI reconstruction were able to return to the elite sport level. Blokland et al 3 reported a similar RTS rate of 88.5%, but only 23.1% were able to return to a similar previous level of athletic performance. In their 2018 systematic review of RTS in 524 patients across 92 studies, Everhart et al 8 reported an RTS rate of 59.1% in all surgical patients. However, their review of the literature included studies spanning as early as the 1950s and does not account for the evolution of surgical techniques and rehabilitation.
The overall RTS rate after MLKI determined in our study (90%) is consistent with the RTS rates in young athletes after ACLR published in other studies. 10,23 Zampogna et al 23 reported an overall RTS rate of 92% in collegiate athletes after ACLR and rehabilitation. Kay et al 10 also found similar results in their study, demonstrating that 92% of adolescents were able to RTS in general, 81% to competitive play, and 78.6% to preinjury level of play after ACLR. However, some studies have reported lower RTS rates in amateur American football athletes after ACLR. In their 2012 study evaluating RTS in high school and college football players, McCullough et al 12 reported 63% and 69% RTS, respectively. Like our study, these authors reported that only 43% of athletes were able to perform at the previous level played.
Previous literature has demonstrated a significant association between psychological factors and RTS after ACLR. 15,21 Specifically, fear of reinjury plays a major role in an athlete’s ability to successfully return to play. In their 2018 study on the effect of fear on athletic performance and ipsilateral reinjury after ACLR, Paterno et al 15 reported that athletes with a Tampa Scale of Kinesiophobia score of >19 at the time of RTS were 13 times more likely to reinjure the ipsilateral ACL within 24 months. While previous literature has not demonstrated a direct association between depression or anxiety on ACLR outcomes, these mental health diagnoses have been associated with increased pain and avoidance postoperatively, which may indirectly affect outcomes. 21 Our study did find that higher ACL-RSI scores were associated with statistically significant higher RTS rates, which may indicate a role for psychological readiness, mental fortitude, and outlook in the postoperative period after MLKI. As with the ACLR literature, our study did not find a statistically significant association between a concurrent diagnosed mental health disorder and RTS rate.
We found participation in cutting sports to be associated with a reduced ability to RTS at preinjury or higher levels. Brophy et al 5 published similar findings in their 2012 study on RTS in soccer players after ACLR, reporting an RTS rate of 72%, with only 36% still playing at 7 years postoperatively. Aizawa et al 1 studied the association between mental readiness and RTS in sports involving cutting, pivoting, and/or jumping and found that lower kinesiophobia score, higher subjective running ability score, and greater limb symmetry were highly associated with mental readiness to RTS. This indicates a strong association between mental preparedness and returning to sports that require cutting and/or pivoting. Athletes in these sports may require longer postoperative rehabilitation.
Previous literature has demonstrated a higher RTS rate in patients sustaining concurrent ACL and MCL tears versus those with combined ACL and PCL, LCL, and/or PLC tears. 2 In their retrospective cohort study, Bakshi et al 2 reported that athletes who sustained ACL/MCL combination tears had a higher RTS rate, shorter time to RTS, and a greater likelihood of returning to their previous level of performance versus those with involvement of the ACL and PCL and/or LCL. In line with these results, our study found a trend toward increased RTS rates in athletes with ACL and MCL combination tears compared with those with ACL and PCL/LCL/PLC involvement (50% vs 25%, respectively; P = .225). However, this finding was not statistically significant in our study—likely because of the relatively small cohort.
Limitations
Our study is not without limitations. Most importantly, our overall sample size of 30 patients is relatively small and demonstrates a low overall rate of follow-up (26%). However, this is similar in size to other MLKI studies. It is also known that studies involving a young cohort of patients have lower overall follow-up rates due to being a mobile population and one that is therefore difficult to contact. Second, we were unable to comment on 4-ligament injuries, as we did not receive responses from these patients. Third, the increased amount of time between surgery and survey administration may have created a recall bias. Furthermore, there was a large range of follow-up times between responders, which may affect the rate of RTS among these patients (see Table 1). Future studies may be able to demonstrate a more objective system for determining RTS or provide surveys prospectively over a consistent period to prevent these biases. Because some patients in this cohort sustained multiple injuries at the time of their MLKI, it is unclear whether concurrent injuries in some patients were confounders and affected RTS. A larger sample size in the future may be able to help adequately answer this question. Next, studies have investigated the effect of different graft tissues for ACLR on RTS rates, 7 of which we were not adequately powered to perform here. This is a variable that should be assessed further in multiligament reconstruction in young athletes. Last, our study does span an 18-year period in which there have been advancements in surgical techniques and rehabilitation protocols. This may have contributed to differences in outcomes between patients. We recognize that these limitations, specifically our small sample size, are significant and affect the impact of the findings reported here.
Despite these limitations, our study provides statistically significant and clinically useful information regarding MLKI and RTS in young athletes over a relatively long follow-up period. Previous studies have examined the RTS rate in young athletes after isolated ACL tears. To our knowledge, this is the first study to look at the RTS rate, the capability of performing at prior performance level, and secondary factors affecting RTS specifically in young athletes after MLKI. These findings can provide a framework for future higher-powered investigations and will allow physicians to provide a more accurate prognosis for young athletes despite the morbidity associated with MLKI.
Conclusion
Young athletes have a high possibility of returning to sports after MLKI and reconstruction. In this cohort, athletes with MLKI had a similar overall rate of RTS as athletes with isolated ACL tears but may experience a lower rate of return to preinjury level of participation. An athlete’s involvement and performance in fast-cutting and/or pivoting sports may be especially reduced after MLKI. Although limited by the follow-up rate, this study provides useful prognostic information for young athletes as they pursue sports after MLKI. We hope that these data provide a foundation for further research on this important topic.
Appendix
Appendix Table A1.
Characteristics According to Study Participant a
| Level of Sports | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Patient | Age, y | Sex | Ligaments Injured | Ligaments Reconstructed | Meniscal Tear | Meniscal Surgery | Sports Played | Preinjury | Postop | Postop vs Preinjury | Concurrent Mental Health Diagnosis |
| 1 | 18 | F | ACL, MCL | ACL | None | — | Soccer | NCAA | NCAA | Same | PTSD, anxiety, depression |
| 2 | 19 | M | ACL, PLC | ACL, PLC | Lateral | Partial lateral meniscectomy | Basketball | NCAA | NCAA | Above | None |
| 3 | 17 | M | ACL, MCL | ACL, MCL | Lateral | Lateral meniscal repair, partial meniscectomy | Football | HS junior varsity | NCAA | Above | None |
| 4 | 15 | F | ACL, LCL | ACL, LCL | Medial and lateral | Medial meniscal repair, lateral meniscal debridement | Track and Field | HS junior varsity | HS junior varsity | Same | None |
| 5 | 18 | M | ACL, MCL | ACL, MCL | Medial | Partial medial meniscectomy | Basketball | Rec | Rec | Somewhat below | None |
| 6 | 19 | M | ACL, MCL, PCL | ACL, MCL | None | — | Horse jockey | Pro | Pro | Same | None |
| 7 | 20 | M | PCL, PLC | PCL, PLC | None | — | Football | HS junior varsity | None | None | None |
| 8 | 18 | M | ACL, PLC | ACL, PLC | None | — | Martial arts | Rec | None | Somewhat below | None |
| 9 | 17 | M | ACL, MCL, PCL | ACL, MCL, PCL | Lateral | Partial lateral meniscectomy | Football | HS junior varsity | Rec | Same | None |
| 10 | 13 | M | ACL, LCL | ACL, LCL | Lateral | None | Football | Rec | None | Significantly below | Depression |
| 11 | 17 | M | ACL, PCL, LCL | ACL, PCL | None | — | Basketball | HS junior varsity | Rec | Somewhat below | None |
| 12 | 12 | F | ACL, MCL | ACL, MCL | None | — | Basketball | HS junior varsity | NCAA | Same | None |
| 13 | 22 | M | ACL, PLC | ACL, PLC | None | — | Soccer | HS varsity | Rec | Somewhat below | None |
| 14 | 21 | M | ACL, LCL | ACL, PLC | None | — | Track and field | HS junior varsity | NCAA | Above | None |
| 15 | 20 | M | ACL, LCL, PLC | ACL, PLC | None | — | Football | NCAA | NCAA | Somewhat below | None |
| 16 | 17 | F | ACL, PLC | ACL, PLC | None | — | Softball | HS varsity | None | Significantly below | None |
| 17 | 17 | M | ACL, PLC | ACL, PLC | None | — | Football | HS varsity | None | Somewhat below | None |
| 18 | 23 | M | ACL, MCL | ACL, MCL | None | — | Motocross | Rec | Rec | Significantly below | None |
| 19 | 21 | M | ACL, PLC | ACL, PLC | None | — | Football | Rec | None | Significantly below | Depression |
| 20 | 18 | M | ACL, MCL, PCL | ACL, MCL, PCL | Medial and lateral | Medial meniscal repair, partial lateral meniscectomy | Rugby | NCAA | None | Significantly below | None |
| 21 | 19 | M | ACL, MCL | ACL | Lateral | Lateral meniscal debridement | Football | HS varsity | NCAA | Same | None |
| 22 | 17 | F | ACL, MCL | ACL, MCL | None | — | Soccer | HS junior varsity | None | None | None |
| 23 | 18 | M | ACL, PLC | ACL, PLC | None | — | Football | Rec | None | None | None |
| 24 | 18 | M | ACL, MCL | ACL, MCL | Lateral | None | Wrestling | HS varsity | Rec | Somewhat below | None |
| 25 | 17 | M | ACL, MCL, LCL | ACL, MCL, PLC | Medial and lateral | Medial and lateral meniscal repairs | BMX | Rec | Rec | Above | None |
| 26 | 19 | M | ACL, MCL | ACL, MCL | Lateral | Lateral meniscal repair | Downhill skiing | Rec | None | Significantly below | None |
| 27 | 20 | F | ACL, MCL | ACL, MCL | Medial and lateral | Medial and lateral partial meniscectomies | Dance | NCAA | NCAA | Same | None |
| 28 | 22 | M | MCL, PCL | PCL, MCL | None | — | Football | HS junior varsity | None | Significantly below | None |
| 29 | 15 | M | ACL, MCL, PCL | ACL, MCL, PCL | Lateral | Partial lateral meniscectomy | Motocross | Rec | None | Same | None |
| 30 | 15 | M | ACL, MCL, PCL | ACL, MCL, PCL | None | — | Football | HS junior varsity | HS junior varsity | Significantly below | None |
a Dashes indicate areas not applicable. ACL, anterior cruciate ligament; BMX, bicycle motocross; F, female; HS, high school; LCL, lateral collateral ligament; M, male; MCL, medial collateral ligament; NCAA, National Collegiate Athletic Association; PCL, posterior cruciate ligament; PLC, posterior lateral corner; Postop, postoperative; Pro, professional; PTSD, posttraumatic stress disorder; Rec, recreational.
Appendix Table A2.
Patient-Reported Outcome Scores According to Study Participant a
| Patient | ACL-RSI | IKDC-SF | SF-12 Physical | SF-12 Mental |
|---|---|---|---|---|
| 1 | 60 | 94.3 | 56.8 | 57.9 |
| 2 | 100 | 85.1 | 56.8 | 57.9 |
| 3 | 100 | 100 | 56.6 | 60.8 |
| 4 | 62.1 | 100 | 56.8 | 57.9 |
| 5 | 63.8 | 63.2 | 42.7 | 60 |
| 6 | 86.7 | 97.7 | 55.2 | 57.8 |
| 7 | 55 | 60.9 | 42.8 | 48.6 |
| 8 | 73.1 | 87.4 | 52.4 | 42.4 |
| 9 | 55 | 93.1 | 55.5 | 57.8 |
| 10 | NA | NA | NA | NA |
| 11 | 93.75 | 88.5 | 53.8 | 55 |
| 12 | 81.7 | 85.1 | 56 | 49.8 |
| 13 | 58.75 | 73.6 | 55.7 | 49.3 |
| 14 | 90.4 | 80.5 | 51.5 | 52.9 |
| 15 | 84.2 | 93.1 | 56.8 | 57.9 |
| 16 | 13.3 | 57.5 | 43.7 | 53.3 |
| 17 | 60 | 88.5 | 54.1 | 55.6 |
| 18 | 58.3 | 44.8 | 25.4 | 60.1 |
| 19 | 24.6 | 66.7 | 48.6 | 31.5 |
| 20 | 34.2 | 89.7 | 60.6 | 41.1 |
| 21 | 85 | 88.5 | 59.3 | 41.9 |
| 22 | 48.75 | 44.8 | 42.8 | 54.6 |
| 23 | 21.7 | 44.8 | 42.5 | 36 |
| 24 | 86.7 | 82.8 | 54.2 | 56 |
| 25 | 77.5 | 65.5 | 36 | 57.7 |
| 26 | 54.6 | 65.5 | 55.9 | 55.9 |
| 27 | 100 | 100 | 55.2 | 60.7 |
| 28 | 46.7 | 48.3 | 49.4 | 57.3 |
| 29 | 65.8 | 87.4 | 54.3 | 55.4 |
| 30 | 34.2 | 93.1 | 57.5 | 51.1 |
a ACL-RSI, Anterior Cruciate Ligament–Return to Sport after Injury; IKDC-SF, 2000 International Knee Documentation Committee Subjective Knee Form; NA,not applicable; SF-12, 12-Item Short Form Health Survey.
Footnotes
Final revision submitted February 2, 2023; accepted March 9, 2023.
One or more of the authors has declared the following potential conflict of interest or source of funding: G.T. has received education payments from Gemini Mountain Medical and hospitality payments from Desert Mountain Medical. R.C.S. has received education payments from Gemini Mountain Medical and hospitality payments from Smith & Nephew. D.L.R. has received education payments from Gemini Mountain Medical and hospitality payments from Arthrex. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from the University of New Mexico (No. 21-068).
References
- 1. Aizawa J, Hirohata K, Ohji S, Ohmi T, Koga H, Yagishita K. Factors associated with psychological readiness to return to sports with cutting, pivoting, and jump-landings after primary ACL reconstruction. Orthop J Sports Med. 2020;8(11):2325967120964484. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Bakshi NK, Khan M, Lee S, et al. Return to play after multiligament knee injuries in National Football League athletes. Sports Health. 2018;10(6):495–499. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Blokland D, van Ooij B, Reilingh ML, Wolterbeek N, Zijl JAC. Low rate of return to pre-injury level of sports after multi-ligament knee injury: functional outcomes after MLKI. Knee. 2021;33:65–72. [DOI] [PubMed] [Google Scholar]
- 4. Borque KA, Jones M, Balendra G, et al. High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes. Knee Surg Sports Traumatol Arthrosc. 2022;30(10):3393–3401. [DOI] [PubMed] [Google Scholar]
- 5. Brophy RH, Schmitz L, Wright RW, et al. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med. 2012;40(11):2517–2522. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Dean RS, DePhillipo NN, Kahat DH, Graden NR, Larson CM, LaPrade RF. Low-energy multiligament knee injuries are associated with higher postoperative activity scores compared with high-energy multiligament knee injuries: a systematic review and meta-analysis of the literature. Am J Sports Med. 2021;49(8):2248–2254. [DOI] [PubMed] [Google Scholar]
- 7. DeFazio MW, Curry EJ, Gustin MJ, et al. Return to sport after ACL reconstruction with a BTB versus hamstring tendon autograft: a systematic review and meta-analysis. Orthop J Sports Med. 2020;8(12):2325967120964919. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Everhart JS, Du A, Chalasani R, Kirven JC, Magnussen RA, Flanigan DC. Return to work or sport after multiligament knee injury: a systematic review of 21 studies and 524 patients. Arthroscopy. 2018;34(5):1708–1716. [DOI] [PubMed] [Google Scholar]
- 9. Ithurburn MP, Longfellow MA, Thomas S, Paterno MV, Schmitt LC. Knee function, strength, and resumption of preinjury sports participation in young athletes following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2019;49(3):145–153. [DOI] [PubMed] [Google Scholar]
- 10. Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR. Over 90% of children and adolescents return to sport after anterior cruciate ligament reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2018;26(4):1019–1036. [DOI] [PubMed] [Google Scholar]
- 11. Lindanger L, Strand T, Mølster AO, Solheim E, Inderhaug E. Return to play and long-term participation in pivoting sports after anterior cruciate ligament reconstruction. Am J Sports Med. 2019;47(14):3339–3346. [DOI] [PubMed] [Google Scholar]
- 12. McCullough KA, Phelps KD, Spindler KP, et al. Return to high school– and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med. 2012;40(11):2523–2529. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13. Monson J, Schoenecker J, Schwery N, Palmer J, Rodriguez A, LaPrade RF. Postoperative rehabilitation and return to sport following multiligament knee reconstruction. Arthrosc Sports Med Rehabil. 2022;4(1):e29–e40. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of second ACL injuries 2 years after primary ACL reconstruction and return to sport. Am J Sports Med. 2014;42(7):1567–1573. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-reported fear predicts functional performance and second ACL injury after ACL reconstruction and return to sport: a pilot study. Sports Health. 2018;10(3):228–233. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Rauck RC, Apostolakos JM, Nwachukwu BU, et al. Return to sport after bone–patellar tendon–bone autograft ACL reconstruction in high school–aged athletes. Orthop J Sports Med. 2021;9(6):23259671211011510. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Robyn AD, Louw QA, Baumeister J. Return to play in elite rugby players after severe knee injuries. S Afr J Physiother. 2022;78(1):1629. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18. Schmale GA, Kweon C, Larson RV, Bompadre V. High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction. Clin Orthop Relat Res. 2014;472(7):2168–2174. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Shah VM, Andrews JR, Fleisig GS, McMichael CS, Lemak LJ. Return to play after anterior cruciate ligament reconstruction in National Football League athletes. Am J Sports Med. 2010;38(11):2233–2239. [DOI] [PubMed] [Google Scholar]
- 20. Shelbourne KD, Benner RW, Gray T. Return to sports and subsequent injury rates after revision anterior cruciate ligament reconstruction with patellar tendon autograft. Am J Sports Med. 2014;42(6):1395–1400. [DOI] [PubMed] [Google Scholar]
- 21. Tripp D, Stanish W, Coady C, Reardon G. The subjective pain experience of athletes following anterior cruciate ligament surgery. Psychol Sport Exerc. 2004;5:339–354. [Google Scholar]
- 22. Waldén M, Hägglund M, Magnusson H, Ekstrand J. ACL injuries in men’s professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med. 2016;50(12):744–750. [DOI] [PubMed] [Google Scholar]
- 23. Zampogna B, Vasta S, Torre G, et al. Return to sport after anterior cruciate ligament reconstruction in a cohort of Division I NCAA athletes from a single institution. Orthop J Sports Med. 2021;9(2):2325967120982281. [DOI] [PMC free article] [PubMed] [Google Scholar]