Return to play after knee injury & surgery

How often do normal people return to a pre-injury level of activity after surgery?

Andy: So, in terms of ‘return to play’, there's quite a lot of debate at the moment. A lot of surgeons are opening their hearts and saying only 50% of their patients get back to their pre-injury level of activity. So, for example, general population have a skiing injury, only 50% get back and it’s often thought to be a disappointment or a bad result.

But I would suggest actually that it represents something different. We're dealing with very intelligent people who actually decide to do a risk benefit analysis and they just don't fancy breaking their ACL again, and they decide they'd rather avoid the activity that caused it.

So in terms of our outcome measurements, we say ‘oh their activity has dropped’. But I'd say, ‘perhaps it’s a win-win’ because they get a lovely stable knee, which will protect them long term and they don't do the dangerous thing’.

What return to play is achievable for elite athletes?

Andy: On the other hand, my elite athletes, remarkably have a very, very high return to play. And amongst the 232 footballers I studied when I was sat down in lockdown not working, believe it or not, for under 25s over 98% got back to play, and 90% at the same level (of pre-injury activity).

Over 25s, it was about 90%. So you'd think that's paradoxical but the reality is they have to get back and want to get back - and they're prepared to take the risk of a repeat rupture.

But the other thing to say is when I've studied my elite athletes who have redo surgery, they still have a return to play of 90%. And we have a big series of these. So its not as devastating in terms of return to play but whether or not that's sensible for the health of their knee in the long term is a different matter.

So actually when my normal patients, my normal population patients have ACL surgery, I'm not too upset if they don't get back because I think, as I say, its probably a win-win. And long term they probably have healthier knees.

As my father in law says, the only people he knows who are friends of his who've had joint replacements, were all brilliant at sports.

Is there a longer term price to pay for competitive sports?

Andy: I know sport is a good thing and I know we need to encourage people to keep fit but I can tell you there's a price for sport - and that is osteoarthritis long term. And we are seeing young men and women playing elite level sport, now that the UK has learned to play sport properly.

In my lifetime, as a kid, we never won a medal at the olympics, we just weren’t competitive, we never beat the Australians or New Zealand at rugby. We do now, but we do because we play harder and we load the body worse, so we're getting more and more arthritis as a result of playing aggressive sport. So, how you measure success is quite interesting.

Can a patient's motivation affect their surgical outcome?

Andy: If somebody wants to get back to high level sport, I can get them back, in the vast majority of cases - even elite sports, where you'd think it would be harder. But everything is on my side...

We've got a patient who's motivated - they want to play. Whereas Joe public, very reasonably, might not want to do all the rehab that's necessary to get back to their level of pre-injury sport. And perhaps they're sensible saying, ‘actually I won't go skiing anymore’. So, there's a real balance to how we measure success.

Mr Andy Williams and Mr Jonathon Lavelle have created an environment at Fortius Clinic where specialist surgeons can flourish in the area of sports injury.These surgeons are supported by a multidisciplinary team of clinicians - from specialist nurses, physiotherapists and sports medicine consultants. Amongst others, the Fortius Clinic team also includes consultant rheumatologists, vascular surgeons and pain medicine specialists.