Return to Play After an Anterior Cruciate Ligament Injury: Prioritizing Neurological and Psychological Factors of the Decision-Making Algorithm

Abstract

Soccer players recovering from anterior cruciate ligament (ACL) injuries have better options for treatment today than they did 25 years ago. Surgical techniques have improved, and rehabilitation protocols have evolved considerably. Although the rehabilitation community is doing a better job of treating this patient population, the evidence does demonstrate that both re-injury and return- to-play (RTP) rates are still suboptimal. Most protocols focus on normalizing strength and range of motion (ROM) and achieving limb symmetry with soccer-specific movements. While these factors are certainly prerequisites for returning to the field, their inclusion does not provide a complete picture of the athlete's presentation. An additional factor that should be prioritized with this patient population is the central nervous system (CNS). Advanced imaging has shown that peripheral deafferentation does occur with musculoskeletal injuries; this ultimately results in cortical reorganization, which makes movement planning more difficult for the player, since simpler tasks must now be processed at higher levels in the CNS. The evidence also shows that the CNS demonstrates plasticity in these cases, so that through focused neuromotor rehabilitation techniques, it is possible to bring movement planning back down to a sub-cortical level. Cognitive issues may also be a factor in preventing the player from returning. Fear of re-injury and diminished confidence can influence the way the player moves on the field, and diminish ability to demonstrate protective kinematics with all soccer-specific tasks. We believe that an approach incorporating traditional musculoskeletal rehabilitation, CNS neuro-motor training, and consideration for cognitive factors, may define an improved paradigm for treating the soccer player and assessing readiness for RTP following ACL injury.