Persistent neuromuscular deficits and injury risk after return to play A 24-month prospective follow-up in elite handball players following ACL reconstruction
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Return to play (RTP) after anterior cruciate ligament (ACL) reconstruction is often considered the final milestone of rehabilitation; however, the extent to which athletes achieve full neuromuscular recovery at this stage remains unclear. Persistent deficits in strength and neuromuscular control may increase the risk of reinjury, particularly in physically demanding sports such as handball. The purpose of this study was to investigate neuromuscular performance, functional knee status, and injury incidence during the first 24 months following RTP in elite handball players after ACL reconstruction, and to explore potential associations between neuromuscular deficits and subsequent injuries. Seventeen elite Greek handball players (8 males and 9 females) who had returned to full competitive activity after ACL reconstruction were prospectively monitored for two years. Neuromuscular performance was assessed every six months using isokinetic dynamometry at angular velocities of 60°, 180°, and 300°/sec, while knee function was evaluated using the International Knee Documentation Committee (IKDC) subjective questionnaire. Strength deficits, hamstring-to-quadriceps (H/Q) ratios, and peak torque-to-body weight ratios were analysed, and both ACL reinjuries and other lower-limb injuries were systematically recorded. Descriptive statistics, chi-square analyses, and repeated-measures ANOVA were applied. ACL reinjury occurred in 35.3% of the participants, with most cases observed within the first six months after RTP. In addition, 28 other lower-limb injuries were recorded, predominantly affecting the previously injured limb. Isokinetic assessments revealed persistent quadriceps and hamstring strength deficits and asymmetries in H/Q ratios throughout the monitoring period, while only 23.3% of IKDC scores reached normative reference values. These findings indicate that athletes may return to high-level competition despite incomplete neuromuscular recovery, potentially increasing reinjury risk. Systematic post-RTP monitoring and objective performance-based criteria may therefore be critical for improving long-term athlete health and safe participation in elite sport.
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