Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're highlighting the science of return to sport. Joining me is Dr. Joshua Reside. He's a fellowship-trained orthopedic surgeon and sports medicine specialist at the University of Florida College of Medicine.

Dr. Reside, thank you so much for joining us today. When an athlete, for example, tears their ACL, one of the first things they always want to know is when can I play again? This is a big deal in sports today, whether it's, you know, soccer players or high school, collegiate, or even the pros. What does return to play actually mean when we're looking at a professional such as yourself?

Dr. Joshua Reside: Yeah. Thanks for having me, Melanie. You know, it's one of those injuries that is very common, especially in our high school athlete population that I mostly see in our Ocala, Florida area. And what an ACL tear is is basically the ACL is a dynamic stabilizer of the knee. And it's for pivot, change of direction, rotation.

And so, when the ACL tears, you know, it's really important that we fix the ACL, and we usually do that through a reconstruction. There are some repair techniques that we can use, but usually a reconstruction, which means using either a graft tissue from your own body or allograft tissue, or other known as cadaver tissue.

So in our high school athletes, it's mostly going to be autograft tissue, and I like to use either the quadriceps tendon or the patellar tendon with a couple of bone plugs on each end. And the biggest thing when patients come in with an ACL tear, obviously, we talk about all those things that I just mentioned. But usually, what's on the mind of the athlete is how long are they going to be out of sports, and when can they come back to playing?

And I think it's a pretty complicated response to that, because there's so many things that go into returning back to sports. And then, what does returning back to sports actually mean? And so, what I mean by that is, you know, if you're a football player and you're playing in high school. And let's say you're even being recruited for college, returning back to sports isn't just getting back and putting your pads on and sitting on the sidelines. Returning to sports is going to be for me, going back to performing at that same level. And so, I think there's sort of three phases to returning to sports. It's, you know, returning to participation in that sport, returning to competitive play in that sport, and then returning to the same performance level in that sport.

And I think there's a lot that goes into that. You know, there's a timeline that we use for all this, which usually gives us a good indication of biological healing. But that timeline of things doesn't necessarily predict how much muscle you'll have in your quadriceps to be able to go back to play. It doesn't tell us if you're psychologically ready to go onto the field and do what you need to do to return to that sport without doing those same sort of motions, the cutting, the pivoting that caused the injury to happen in the first place, there's sometimes a little bit of trauma, you know, in that athlete's mind to do those same sort of maneuvers that eventually led to them having a very serious injury. There's limb symmetry. So after an injury, after an ACL tear, there's quite a bit of quadriceps strength loss in the knee, and that's also sort of multifactorial. There's arthrogenic muscle inhibition. There's also just some atrophy of the muscle, because the quadriceps muscle gets weak.

And so, all of these things sort of play into returning back to sports. And these are all conversations I like to have with the athlete when I first see them in the office to sort of give them a timeline of what to expect after they have surgery. The first six weeks after, what do the first three months look like? When can they get back to jogging? So, we talk about all those things in the preoperative visit, discussing the types of grafts and when to expect to come back to sports.

And on top of all that, we also get some objective testing where we look at the strength in the operated leg versus the unoperated leg, and we try to get those pretty close to being back to normal before that athlete goes back. So, very multifactorial, and I'm just sort of touching the tip of the iceberg on each one of those sort of topics that plays into returning back to sports.

Melanie Cole, MS: That was a very comprehensive answer, Dr. Reside. You and I could really talk about this for a long time. It's a hot topic in sports today. It really is. And since the road to recovery is really never the same for two people, and the sport they're returning to certainly would affect your criteria as you're telling us about the milestones that you look for. What are some of the major factors that you see that inhibit recovery? Now, you mentioned psychological readiness, and we are going to get into that for sure. And strength, symmetry, quality, confidence, I mean, there is a whole lot that goes into it, as you say, but what are some of the factors that inhibit that recovery when we're looking for the criteria that you use to determine readiness?

Dr. Joshua Reside: Yeah. We usually get patients into physical therapy right away. And sometimes some of the inhibition to someone's rehab is actually getting access to physical therapy. We oftentimes will run into issues with insurance companies not paying for physical therapy visits, and families have to make tough decisions about paying out of pocket for certain physical therapy costs and how often they're going as far as once a week or once every other week.

And so, that's one that I'll commonly see, especially in our population down here in Ocala is there's a little bit of inhibition with sometimes physical therapy being covered by insurance companies. And I've had some patients where it's been a struggle to keep them consistent with the rehab and progression through all of that without the guidance of a physical therapist.

And so, physical therapists play a huge role in recovery. And along those same lines, the athletic trainers at the school do a fantastic job getting those athletes ready. And it comes down to those athletes buying into the rehab and owning it as far as them having to actually show some ownership in their recovery to get back to the level that they want to as far as performance in their sport.

And so, I would say that would be probably the biggest inhibitors to getting back. or having access to a gym to work on their strengthening having time during their school days and transportation to and from not just physical therapy, but a gym they may be using.

And then, sometimes just biology. Sometimes with an ACL tear, we'll also see meniscus tears. We'll see collateral ligament injuries with the MCL or LCL. We'll see multiligamentous knee injuries. All of those sort of things can—I wouldn't necessarily say inhibit, but sort of delay their recovery to coming back to a sport and sometimes prevent them even from coming all the way back to the same performance level. And so, those are just some of the reasons I can think of that at least I've seen as far as patients being inhibited or going back to participating in their sport.

Melanie Cole, MS: Yeah. So, let's talk about sports psychology here, which in itself is also now a burgeoning field that we're learning more and more about. So, speak about the mental side of returning, Dr. Reside. So, fear of re-injury, obviously confidence, those things affect readiness. We've learned that athletes can be physically capable, but psychologically hesitant. So, how can physicians, therapists, athletic trainers, coaches, even the parents of athletes work together to assess whether a player is psychologically ready? What do you do when you're speaking to these professionals and helping them to guide the athlete?

Dr. Joshua Reside: When I give a clearance for somebody to go back to playing their sport, a medical clearance, that's very different than being ready to go back to play. So based on our numbers and based on our objective findings and our physical findings, you're right, sometimes patients are ready to go back.

And so, there's been a lot of research in this area, and there are some things and some tools that I can use as a surgeon to help assess that readiness. Some of those things are questionnaires. Some of that is just my assessment, talking with the patient, asking them, you know, if they're ready to go back and sort of if they're ready or what concerns they may have about going back.

But it really is a team approach to going back to this. And what I mean by that is I want to know what their physical therapist thinks when they're watching them do their exercises as they go back. And so, oftentimes at the end of their rehab, we'll have them return back to pivoting and changing direction and rotating. And they'll do those things in front of their physical therapist. And I want to know what their physical therapist thinks if there looks like there's any hesitation.

Another huge advantage that we have is our athletic trainers at our high schools in Ocala at least they know these athletes. They are with them at practices. They're with them at games. They know how these athletes move normally and what their baseline is. And so, I really rely on their judgment as far as, you know, watching these athletes as they recover to get back to doing the same things that they were doing before and doing it in a safe way. There's a lot, I think, that goes into that.

And then, I think the last thing that I'll mention is when we talk about going back to playing sports, there's a little bit of a controversy on whether or not bracing will make a difference. And so, we'll oftentimes order a brace. In the literature, there's been no findings that have shown that the brace prevents any re-injury of the ACL graft specifically. But there are some studies that show that, psychologically, it may help patients and athletes get back to playing just having the brace on.

On the flip side of that, there are some studies that argue that having that brace on may change the way that the athlete would normally move. And so, it's definitely controversial. And usually towards the end of the rehab, I'll have a conversation with the patient to see if they're interested in wearing a brace. And I would say most of my patients usually feel more comfortable going back to playing at least starting with the brace on. And then, over time, they may find it easier to get around and to move without it. But all of those things sort of play into getting an athlete psychologically ready to go back to play.

Melanie Cole, MS: Yeah, bracing is an interesting topic in itself, right? So when we think of re-injury, Dr. Reside, can we predict who's going to be at a higher risk of tearing their ACL? I suppose that some of it's going to be adherence and compliance, as you said, physical therapy, making sure that they're doing prehab before surgery and, you know, rehab afterwards and really keeping up with that. But what do you see most often when re-injury happens? Does it happen too quickly? Are they not ready? Tell us what you see.

Dr. Joshua Reside: Yeah. So, there's a lot of different reasons that that can happen as well. You mentioned prehab and things like that. I think that's always really important. I tell patients that, after surgery, we know that there's going to be atrophy of the muscle, the quadriceps muscle especially. We know that there's going to be some stiffness in their knee as far as range of motion that we'll have to get through with rehab. So, I always tell patients that, before we even do the surgery, wherever we start as far as our strength and our range of motion, we know that there's going to be a dip after surgery.

And so if we can start that in a better spot be a little bit stronger, make sure our range of motion is in a really good place, then that dip that we have after surgery won't be as far down if we prepare the knee with prehabilitation. So, I think that's where that comes in, and that can even sort of get us in a better starting point when we start our rehab, which can definitely speed things along as far as that recovery timeline and getting back to where we need to.

And so, I think it starts there. And then, throughout the process, there's the biological healing of the actual graft that we put in for the reconstruction. I usually tell patients that around three months or so, we're expecting the graft to be pretty much healed at that point, any meniscus injuries to be healed at that point. The range of motion around that time should be pretty close back to normal.

And then, what we have for the rest of the rehab is getting the strength back, and that's what takes the longest to get back. And it's the same for everyone, even the professional athletes in the NFL that have every resource available to them, they have physical therapists that work with them every day, they have a chef that's cooking their meals, even those patients, it still takes them the same amount of time to get back to sports. And it really just comes down to there's no cheat code of getting that muscle back other than just putting in the hard work.

And so, as patients get back to playing, I think that we see re-injuries—if we see someone with an ACL injury in the first place, we know that they're playing at a level, they're cutting, they're pivoting, they're doing something at a high energy level that has the propensity to cause an ACL injury.

And so, those athletes, when they go back to playing the same sport with the same amount of energy that they played with to begin with, they're just inherently at risk of also either re-tearing the same knee or injuring the other knee. And I've seen that in my practice, not necessarily as much on the same knee, but on the other knee, of having a patient tear their ACL, say, on their left knee, and then, you know, a year later or eighteen months later, injuring the other side.

And when that happens, we start to look for some other things of why would this be happening as far as their posterior tibial slope is the alignment of their leg in such a way that puts them at risk, if their knee is valgusing, for example. Especially in female athletes, we look at the the biofeedback of landing from a jump. A lot of women will have their knees sort of buckle in or go knock-kneed. And so, recognizing that and trying to correct those things with biofeedback is where our physical therapists come in to help try to learn different ways to land with our knees, to put us in positions that don't put the ACL at risk of tearing.

And then, there's been a lot of studies that look at other things that increase the risk of ACL injuries, even concussions for some reason. They're not exactly sure the direct correlation with that, but patients that have concussions are at higher risk of tearing their ACLs. There's just so much interesting connections to athletes that are playing these high-level sports and putting so much energy through their knees and playing physically. There's so many different connections to an ACL injury, and it's really interesting to learn about those things, because it helps us in the prevention department of trying to prevent these injuries from happening in the first place.

Melanie Cole, MS: Yeah, that's so important. You made so many great points, and that's interesting about concussion and ACL risk. You know, we know females have that higher risk of ACL injury, but concussion, that's an interesting field of study right there. So Dr. Reside, as we get ready to wrap up, when you think about patients, whether they are collegiate, professional, or even weekend warriors, you know, when we think about cross-training and chronic overuse, not so much acute injuries as we're talking about here today, what would you like patients to ask their surgeon or physical therapist before returning back to normal activity? And since readiness is really not about always what an athlete can demonstrate, but how long it's been since surgery and what they are really ready for, if you could leave them with one piece of advice about returning to sport after an injury, what would that be?

Dr. Joshua Reside: I think when you're thinking about going back to playing sports, there's sort of three phases of that, right? You have your physical readiness, you have the biological readiness, you know, is everything healed? And you have the psychological component to, am I ready to go back and play and commit to doing those moves that I used to do in my sport that maybe have ultimately led to your injury.

And so, I think for the biological component, that's where the timeline comes in as far as just how far out after sports. And there's been some pretty good studies that have shown that around a nine-month mark is a good benchmark as far as having, like, a minimum. And so, there's a pretty good study that showed that patients that return to sports before nine months had a higher re-injury rate to the same knee as far as a graft risk.

And so, I think at least having those nine months to really work hard on the rehab is important. I think the second phase of that is the physical readiness. And so, that's not only getting the strength back in your quadriceps muscle, but looking at the symmetry of the leg compared to the other side.

And so, we usually will get a Biodex test. And what that does is it compares the strength in the uninjured leg and compares it to the surgically reconstructed leg. And what we like to see with that is a less than 10% symmetry deficit. And so, we want that strength to come all the way back to at least within 10% of the other leg that wasn't injured.

And what that does is the quadriceps muscle is so dynamic that it protects the graft. And so when you're running, when you're landing, when you're jumping, your quadriceps muscle is doing a lot of the work as far as absorbing that energy. And if you're weak in the quadriceps muscle and it's not like the other side, you may be putting the graft at risk. And so, I think at least, you know, waiting around nine months or so for the biological healing of everything, I think getting the quadriceps strength back and the limb symmetry.

And then, like I said before, as far as that psychological readiness, that's sort of a multifaceted approach between the physical therapist, between me as the surgeon, between their athletic trainer and the athlete really coming together as a team and deciding are we ready to go back.

And what that looks like necessarily isn't just, okay, we're clear to go back, and we're right back in the game. What a clearance back to sports looks like is, you know, you get back to doing individual drills on the sidelines where we're controlling for all the variables. You don't have anybody else that's coming at your leg or trying to take the ball away from you. We're not running on wet grass. You know, we're trying to control those unknown variables to try to be in a very controlled setting to do those things. Then, we sort of graduate on to practices without contact. Then, we graduate on to practice with contact. So, even a clearance back to playing and getting back to doing those things may take several months before you're getting back to actually playing at the same competition level.

And for some of my athletes, they do get back to returning at the same performance level. But sometimes that can take even up to a year to get that confidence back, to get the strength all the way back and to really feel like you're getting back to doing what you love to do at the same level that you were previously.

Melanie Cole, MS: What a great episode this was. What a great discussion. Dr. Reside, thank you so much for joining us today and sharing your incredible expertise in this really hot topic that is so interesting for all the people that are involved with these athletes, whether it's a coach or a parent or the athletic trainers, the physical therapists, and the orthopedic surgeons. You've really given us a lot to think about, so thank you so much.

And to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole.