Article: The old knee in the young athlete: knowns and unknowns in the return-to-play conversation (Ardern CL, Khan KM, British journal of Sports Medicine November 19, 2015, 10.1136/bjsports-2015-095481.)
Written by: Geneviève Rochette Gratton , MD, CCFP, Fellow in Sport & Exercise Medicine at University of Ottawa
Advisor: Dr. Taryn Taylor, BKin, MSc, MD, CCFP (SEM), Dip Sport & Exercise Medicine
In Sport Medicine, we found ourselves frequently having to discuss pros and cons of returning to a certain sport after an injury with our athletes. The article recently published by the British journal of Sport Medicine reviews all the aspect that should be included in a return-to-play conversation. As an example, the authors use a young female athlete who recently sustained an ACL rupture playing amateur football.
In order to help the athlete make an informed decision, it is our job as physician to give our patients accurate information, and guide them in making the right decision.
What we know:
- Regardless of treatment choice (surgical vs non-surgical), the athlete is able to achieve remarkable physical function (meeting impairment-based and activity-based measures)
- Likeliness to return to pre-injury level of sport is doubled in 25 years old and younger compared to older athletes. Young athletes have an increased risk (up to 6 times) of re-rupture or new ACL tear when returning to pivoting sports.
- Following an ACL injury, most (up to 90%) will develop symptoms of patellofemoral osteoarthritis or post-traumatic tibiofemoral within 10 to 15 years.
What we don’t know:
- Is the risk of subsequent osteoarthritis increased with return to pivoting sport? Especially knowing that a new insult could accelerate and increase knee osteoarthritic changes.
- Does retirement for pivoting sport reduce the risk of osteoarthritis?
- What is the impact of early retirement or changing sport on the quality of life of the athlete?
In this article, a few recommendations are made in regards to what should be discussed with the athletes to help them make the most informed decision:
- The athletes are in charge of their return-to-play decision. In order to help them, motivational interviewing has proven efficient to help ease the conversation regarding changing, modifying or stopping their sport as well as helping them understand the risk of going back to pivoting sports.
- It is important to share the decision making with the athlete by explaining the pros and cons of the different treatment options, and to help them understand what is reasonable. In combination with motivational interviewing, this can empower the athlete in making an informed decision.
- The context of the athlete needs to be taking into consideration when talking about risks. Salaries, endorsement, athletic identity, level of sport, pressure from piers (coaches, families, teammates…) are some of the factors that should be included.
It is important to remember that being an athlete in a competitive sport does not equal being healthy. As clinician, we should be aware that an athlete perception of treatment success can differ from ours, and we should not let our own biases lead the conversation regarding return-to-play. We should aim toward a shared decision-making approach, also helping the athlete differentiate performing from being healthy in order for him to make the best return-to-play decision.