Background
Sports injuries often threaten the success and careers of athletes. Some of the injuries are minor and have a less significant impact on athletes; however, some of the injuries are career-ending and have consequences on the quality of life of athletes (Webster, 2019). Furthermore, injuries influence the costs of rehabilitation, which are a concern for athletes or sports institutions, in terms of lost time and monetary expenses (Papadopoulos et al. 2018) . Injuries on athletes impact not only physical physical abilities but also psychological and contextual facets. In some scenarios, injuries can strip athletes of their reparation intensifying life-stress, and govern fear to re-injury, negative sensations , feelings of loss, and other mood troubles (Webster, 2019).
The anterior cruciate ligament (ACL) tear is a prevalent sports injury in both female and male athletes, especially in sports that entail jumping, cutting, or pivoting (Papadopoulos et al. 2018) . More than 200,000 incidences of ACL injuries are recorded annually in the U.S (Papadopoulos et al. 2018) . Similarly, ACL reconstruction is a routine medical procedure in Europe and the USA, with more than 100,000 syndesmoplasties being conducted every year in the U.S and 3500 ACL operations in Sweden (Papadopoulos et al. 2018) . An athlete with an ACL tear who is conservatively treated, with early modification of activity and neuromuscular rehabilitation regime, in a few days or weeks may be able to have a painless knee without edema. Later on, an athlete to some extent, an athlete may be able to return to sports.
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Ardern et al. 2015 in his study defined RTS as the ability to return to the same level of the same sport played by an athlete before the occurrence of the injury. Athletes may accomplish RTS by performing easy sports activities that do not entail jumping, pivoting, or cutting movements. Through this, athletes may evade the stress of the ACL surgery; nonetheless, studies by Ardern et al. 2015 and Webster et al. 2019 show that only 2/3 of those athletes do return to their previous levels of activity before the injury. Athletes undergo an operation to not only circumvent succeeding chondral or meniscal injuries and premature osteoarthritis but mainly to get back to their pre-injury activity levels (Papadopoulos et al. 2018) . There is a persistent correlation between the self-confidence of an athlete, his/her motivation and optimism to recuperate from the injury, and the exact consequence of the surgery. Fear of re-injury may be more dominant in competitive athletes, as they participate in aggressive and unsafe situations, during professional competitions and training, exposing the athletes to injury.
A previous systematic analysis using meta-analysis investigated the rate of return to participation in sports of various kinds in addition to the RTS to pre-injury and professional sports after reconstruction of ACL surgery. Outcomes from forty-eight studies conducted by Ardern et al. 2015 that gave information on outcomes of 5770 ACL patients. The study showed that only 82% of the patients resumed to any sporting activity, while only 63% were taking part in the pre-injury sport they were previously involved in at follow up. In the study, with the inclusion of professional sports, only 44% of the patients were taking part in the follow up process (Webster & Feller, 2019) . The involvement rates compared with the results that approximately 90% of athletes were regarded as regular or almost regular on impairment-centered outcomes, for example, knee laxity and strength (Webster & Feller, 2019) .
An updated study of Ardern et al. 2015 included 69 studies involving 7556 patients. In the updated study, 81% of the athletes resumed to any form of sport, 65% resumed their pre-injury sport, and 55% of the athletes got back to their professional sport (Webster & Feller, 2019) . The overall information from the study was to show that the rates of return to sports are lower than anticipated by an athlete going through a reconstruction of ACL.
Another study conducted by Kay et al. 2018 that focused on the rates of return to sports on younger athletes of 6 to 19 years of age was conducted. The study involved 20 studies of 1156 athletes. In the cohort, 92% resumed any sporting activity, 79% returned to the pre-injury sport, while 81% resumed competitive sport (Kay et al. 2018). Hence, the rates of RTS for younger athletes are relatively higher, which may have consequences for re-injury. In the two studies, the majority of the patient groups discussed had gone through a primary ACL reconstruction. There is a little amount of literature on RTS rates following revision reconstruction. However, a study by Grassi et al. 2015 that incorporated 23 studies involving 1090 athletes revealed identical results to the reviews on primary ACL reconstruction. In the study, 85% of athletes resumed to some sort of sport, 53% return to the pre-injury level they were previously in, and 51% got engaged back in competitive sports. Nonetheless, the review was limited by the obtainability of only four studies in professional athletes, and only two of the studies had (> 100) numbers of patients.
Study design
The study design would be based on meta-analysis and systematic review. We will search through E-databases such as Embase, Medline, CINAHL, and SPORTDiscus for earliest probable entry to 2019. Studies that informed on the number of patients returning to sports activities after undergoing ACL reconstruction operation would be included. After which the results would be presented through a framework of WHO’s International Classification of Functioning, Disability, and Health, and used together with proportion meta-analyses.
Significance
Numerous factors determine whether a person will embark to sport after undergoing reconstruction surgery. These factors include rehabilitation and surgical facets, in addition to demographic, psychological, and social factors (Webster et al. 2018). Factors that influence RTS after ACL reconstruction with supporting literature and empirical information comprise of being male and of younger age (Webster et al. 2018). Averagely, males often have a higher return rate by about 10% while in younger athletes, return rates may surpass that of adults by 30% (Webster et al. 2018).
Athletes who undergo a shorter duration between injury and operation have greater RTS, and furthermore, playing an elite sport level increases the return rate. Outcomes in terms of the type of graft have been used together with hamstring tendon autografts increasing RTS at numerous levels and patellar tendon autografts enhancing going back to the pre-injury sport (Webster et al. 2018) . Adopting a positive psychological response by an athlete has proved to be tightly linked with RTS after the pre-injury (Soneson et al. 2016). High levels of motivation when an athlete is undergoing rehabilitation have been proven to be correlated with higher RTS following ACL reconstruction (Soneson et al. 2016).
Interventions
Interventions such as rehabilitation programs and criteria for return to sports have been of terms of graft maturation (Rambaud et al. 2017) . The second approach that can be employed to the two types of rehabilitation is to utilize a set of protocols or “test-battery” to “clear” the athlete for resuming sports. The protocol is used in the final step of the rehabilitation and athletes who “pass” get cleared to return to sports (Rambaud et al. 2017) . In the determination of the RTS criteria, an extensive “battery test” for quality and quantity of movement must be conducted. The test battery should incorporate a range of hop tests, strength tests, and gauges of quality of movement.
Research by Jay Ebert and his colleagues provided (unpublished) data on post ACL rehabilitation in a community environment of non-elite athletes (Hughes, 2019) . The studies showed that of 111 ACL reconstructed athletes, 9% never attended any supervised physiotherapy within one year, 45% did not go to supervised exercise after three months, and only 30% of the study participants took part in landing, agility and jumping training as a component of rehab (Hughes, 2019) . On the quality of rehab, the studies found that of the 55% athletes, who underwent a minimum of six months of supervised physiotherapy/rehabilitation, were all able to attain 90% or higher limb symmetry through hop and strength tests after twelve months follow up point (Hughes, 2019) .
Moreover, athletes who finished supervised training for more than six months and achieved high-level training procedures, for example, jumping and landing were close to realising 100% limb symmetry in operated and non-operated limbs. Once a patient embarks on a sport, the athlete should carry out a minimum of 2 times every week ACL injury prevention exercises such as PEP, FIFA 11, the remaining duration of their sporting career to minimise the risks of second ACL tear (Hughes, 2019) . In preventing osteoarthritis, it is crucial to take into consideration the rest of the knee when an athlete resumes to sport after ACL reconstruction (Hughes, 2019) . ACL tears are seldom isolated injuries, with regular bruising of the bone, chondral lesions, and meniscal damage.
Conclusion
To conclude, the rate of RTS after ACL reconstruction are frequently minimal than anticipated, and several elements influence RTS. Younger athletes have greater chances of RTS and greater rates of more ACL injuries. Currently, there are no ratified guidelines for determining when it is safe for RTS. Some utilities exist for RTS criteria; these utilities can be employed to provide the patient with feedback concerning the progress of their rehabilitation. Nonetheless, the overall use of these utilities in clearing athletes for RTS in the clinical setting remains unclear due to heightened levels of uncertainty as to their legality concerning the risk of preceding injury. Finally, it must be accepted that any RTS is linked to a danger of more injury, and possibly osteoarthritis development.
References
Ardern CL, Taylor NF, Feller JA, Webster KE (2015) Fifty-five percent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 48(21):1543–1552
Grassi A, Zaffagnini S, Marcheggiani Muccioli GM, Neri MP, Della Villa S, Marcacci M (2015) After revision anterior cruciate ligament reconstruction, who returns to sport? A systematic review and meta-analysis. Br J Sports Med 49(20):1295–1304
Hughes, M. (2019). Return to Sport Following ACL Reconstruction in Young Athletes. Retrieved from https://www.linkedin.com/pulse/return-sport-following-acl-reconstruction-young-athletes-mick-hughes
Kay J, Memon M, Marx RG, Peterson D, Simunovic N, Ayeni OR (2018) 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 26(4):1019–1036
Papadopoulos, S. D., Tishukov, M., Stamou, K., Totlis, T., & Natsis, K. (2018). Fear of re-injury following ACL reconstruction: an overview.
Rambaud, A. J., Semay, B., Pierre Samozino, J. M., Testa, R., Philippot, R., Rossi, J., & Edouard, P. (2017, June 01). Criteria for Return to Sport after Anterior Cruciate Ligament reconstruction with lower reinjury risk (CR'STAL study): Protocol for a prospective observational study in France. Retrieved from https://bmjopen.bmj.com/content/7/6/e015087
Sonesson S, Kvist J, Ardern C, Österberg A, Grävare Silbernagel K (2016) Psychological factors are important to return to pre-injury sport activity after anterior cruciate ligament reconstruction: expect and motivate to satisfy. Knee Surg Sports Traumatol Arthrosc 25(5):1375–1384
Webster KE, Feller JA (2018) Low rates of return to preinjury sport after bilateral anterior cruciate ligament reconstruction. Am J Sports Med 7:0363546518813901
Webster, K. E., & Feller, J. A. (2019). A research update on the state of play for return to sport after anterior cruciate ligament reconstruction. Journal of Orthopaedics and Traumatology , 20 (1), 10.
