Figure 8: Using scales to assess partial weight- bearing

Figure 9: Demonstration of heel-toe-touch down weight-bearing

to lead to altered gait patterns and shortening of the gastrocnemius and soleus muscles; in preference, they should use ‘heel-toe-touch-down’ weight-bearing (Fig. 9). Most athletes want to return to sports-specific skills as soon as possible. A good way to introduce some sports specific-skills earlier in the rehabilitation period is in the pool, using antigravity suits or buoyancy aids to minimise loading on the knee.

RETURN TO SPORT Returning to sports and exercise activity is one of the main reasons given for individuals electing to undergo cartilage repair surgery (30). Function in sports is viewed as an issue of high importance by patients after cartilage repair (31). Cartilage repair rehabilitation is lengthy, and the neocartilage may take up to three years to mature. The big question is how long is it necessary to hold back the athlete from returning to sport?

For any athlete, return to sport is

a risk assessment. First and foremost the athlete has to be ready to accept the load of their sport. If they are not ready to do this, then they should not return to their sport at that stage. Load acceptance is not only the ability of the cartilage repair tissue to accept the load but also the whole person being able to accept the load physically, chemically, biomechanically and psychologically. If the athlete is ready to accept the load of their sport, then the athlete needs to be assessed to determine whether or not the risks of injury/re-injury or future disability outweigh the benefits of returning to the sport. The level of the athlete is

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a consideration in this assessment: for the non-elite athlete it may be a case of looking at long-term survival, whereas for the elite athlete it may be the different scenario of a ‘quick fix’ to enable them to collect a pay cheque for another two or three seasons. Several studies have documented return-to-sport timescales following cartilage repair (see Fig. 4), but these are general guidelines as return-to- sport variables are frequently not assessed or are reported inadequately. Consider managing the returning athlete differently in their first season back by looking at decreasing sessions, increasing cross-training or playing more half-games. A return to pre-injury performance

levels is not guaranteed, and for some athletes articular cartilage injuries may be career-ending. In this instance, the role of the healthcare professional switches to considering how to keep the athlete exercising when they retire from competition. Education on the physical

expectations for an athlete returning from cartilage repair is important. Communication with the athlete, the coach and the management team is crucial. Not all athletes who are physically

ready and able to return to their sport actually do so. In the study by Mithoefer and colleagues, 83% of competitive players returned to football after ACI surgery. However, of the 26 recreational players in the study, 14 players had excellent or good clinical outcomes and yet none returned to football at any level (6). It should be recognised that cartilage repair rehabilitation is a long process and psychosocial factors have an impact on return-to-sport outcomes, as can be seen from the patients in practical example 2, who were both deemed to have excellent clinical outcomes after undergoing cartilage repair procedures.

WHICH ATHLETES DO BEST? Overall published success rates from articular cartilage repair range from 60% to 96% for the general population. Initially patellofemoral joint repairs showed considerably lower success rates compared with tibiofemoral joint repairs. Although this trend continues, the gap is closing. On the basis of studies over the past ten years, there

are indications that some athletes have better outcomes than others following cartilage repair. Athletes who have been shown to do better are those who: n Are younger (<40 years of age) n Have a shorter pre-operative duration of symptoms (<12 months) n Have had fewer previous surgeries n Have smaller defects (<2cm2) n Have any mechanical malalignment corrected before or at the time of the cartilage repair surgery n Participate in lower-impact sports n Are professional or competitive athletes n Are motivated to return.

When treating an athlete who has undergone cartilage repair, the more information you have to hand the better. Find out exactly what the surgery entailed and whether any concomitant procedures were performed. Where possible get copies of the operative notes, MRI reports and any documentation on the precise defect size and location. It is important for exercise selection to know not only which articulating surface has been repaired but also where the surface was repaired – medial, lateral, proximal or distal. Get a copy of the rehabilitation guidelines given to the athlete. Do not assume that cartilage repair centres always use the same rehabilitation guidelines – they don’t!

SUMMARY

Articular cartilage repair has made amazing progress over the past 20 years, but to date the optimal level of mechanical stimulation or the level of pathological overload for repair tissue at different rehabilitation stages has not been determined. The results of cartilage repair studies look increasingly promising, but a universal solution for athletes is not available. No surgical technique is able to regenerate 100% hyaline cartilage, and there is a clinical trade-off associated with all of the current cartilage repair procedures. Any athlete contemplating cartilage repair should be fully informed and aware of the implications before electing to undergo surgery, as a return to pre- injury levels of sports participation is by no means assured.

References 1. Alford JW, Lewis P, Kang RW, Cole BJ.

sportEX medicine 2009:39(Jan):17-21