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Return to Military Duty After Anterior Cruciate Ligament Reconstruction

Article  in  Military medicine · November 2017

DOI: 10.1093/milmed/usx007

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 MILITARY MEDICINE, 183, 1/2:e83, 2018

Return to Military Duty After Anterior Cruciate Ligament

Reconstruction
LTC Ivan J. Antosh, MC, USA*; MAJ Jeanne C. Patzkowski, MC, USA†; Adam W. Racusin, MD‡;
James K. Aden, PhD§; Scott M. Waterman, MD¶

ABSTRACT Background: Return to play and risk factors for functional limitations have been widely reported
among athletes following anterior cruciate ligament reconstruction (ACLR) but has not been well studied in the mili-
tary population. Methods: We conducted a retrospective review of all active duty service members who underwent pri-
mary ACLR at our institution between 2005 and 2010. The primary endpoints evaluated included Medical Evaluation
Board (MEB) and activity limitations as noted by permanent profile (PP) following surgery. Demographic and surgical
information was collected including age, gender, Military Occupational Specialty, tobacco use, rank, associated menis-
cal/chondral injuries, graft type, graft size, graft failure, and subsequent surgeries. All patients were greater than 2 yr
postoperatively from index ACLR. Findings: A total of 470 patients met inclusion criteria for the study. There were
428 men and 42 women with a mean age of 28.5 yr. Of the 470 patients, 247 (52.6%) required either MEB, PP, or
both following surgery; 129 (27.4%) required a PP only; 53 (11.3%) required a MEB only; and 65 (13.8%) required
both PP and MEB following surgery. Only 223 patients (47.4%) returned to full duty without restrictions following
ACLR. Both anterior cruciate ligament graft failure and subsequent surgeries were found to be statistically significant
predictors for PP and/or MEB (p < 0.0001). Age, tobacco use, rank, associated meniscal/chondral injury, graft type,
and graft size were not found to be significant predictors for subsequent PP and/or MEB. Female gender trended
toward significance as a risk factor with 27 of 41 females (65.9%) requiring PP and/or MEB (p = 0.07). Service mem-
bers in a noncombat arms role were more likely to require PP and/or MEB than those in a combat arms role (p =
0.03). Discussion: Return to full duty following ACLR in active duty soldiers is lower than may be expected. More
than 50% of service members have activity limitations or are unable to return to duty following surgery. These findings
allow for preoperative discussion of expected outcome and the possibility that an anterior cruciate ligament tear even
when reconstructed can lead to permanent military activity limitations and MEB.

BACKGROUND 63% returned to preinjury level of participation. Furthermore,

Anterior cruciate ligament injuries are common in young, ath-
letic population.1,2 The incidence of anterior cruciate ligament
(ACL) injury continues to rise, particularly in females and
patients less than 20 yr, and the benefits of anterior cruciate lig-
ament reconstruction (ACLR) continue to become better
defined in terms of optimizing functional outcomes and reduc-
ing the need for future surgery.3–8 Functional outcome scores
after ACLR tend to be good to excellent. A recent, large meta-
analysis including over 5,000 patients by Ardern et al. revealed
functional outcome scores of 85%–90%, but surprisingly only
*Dwight D. Eisenhower Army Medical Center, 300 E Hospital Rd,
Ft. Gordon, GA 30905.
†Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI
96859.
‡Scott & White Specialty Clinics, Marble Falls, TX 78654.
§Institute of Surgical Research, San Antonio Military Medical Center,
San Antonio, TX 78234.
¶Central Indiana Orthopedics, Muncie, IN 47304.
The views expressed in this article are those of the authors and do not
reflex the official policy or position of Department of the Army, Department
of Defense, or the US Government.
doi: 10.1093/milmed/usx007
Published by Oxford University Press on behalf of the Association of
Military Surgeons of the United States 2017. This work is written by (a) US
Government employee(s) and is in the public domain in the US.
only 44% had returned to competitive sport at final follow-up.9
Dunn et al. reported that only 45% of patients returned to the
same or higher level of activity at 2 yr postoperatively in a pro-
spective evaluation of the Multicenter Orthopaedic Outcomes
Network cohort.10 McCullough et al. reported 63% and 68%
return-to-play rates among high school and college football
players, respectively; but only 43% returned to previous level
of play.11 Return to athletic play has been widely studied
among various sports including college and professional ath-
letes with return-to-play rates reported between 45% and
92%.12–25
Military service members may have a higher risk for ACL
injury than their civilian counterparts. Soldiers, specifically
those serving in the combat arms, are required to perform
aggressive impact, daily distance running, and heavy weight-
bearing on a daily basis. These activities often occur on
uneven terrain, with poor visibility, and in high-stress situa-
tions. The risk for knee injury is high among soldiers, and
the pace of deployments over the past decade has served to
increase the demand on soldiers. After ACLR, soldiers may
have difficulty tolerating the activities necessary to perform
their jobs effectively,26–31 and these individuals may require
permanent restriction from certain military requirements or
removal from active duty service.

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 Return to Duty following ACLR
Several previous studies have evaluated the functional
outcomes of ACLR in the military population. Edwards
et al.32 found a 69.9% return to full duty with no difference
between surgical techniques employed (iliotibial band tenod-
esis, patellar tendon autograft, combined iliotibial band
tenodesis/patellar tendon autograft). Additionally, patients
over 30 yr or without associated degenerative disease
returned to full duty at a higher rate than those under 30 yr
or with degenerative findings.32 Cullison et al.33 reported on
143 navy personnel who underwent bone-tendon-bone
ACLR using release to full duty versus medical discharge as
the primary endpoint. Of the 143 navy personnel, 77% of
patients returned to full duty, whereas 23% were medically
discharged. The authors did not differentiate any permanent
restrictions in those who returned to full duty. Patients at
higher military rank including officers and senior enlisted
had higher return-to-duty rates than those at lower rank.33
Dunn et al.34 reported on 2,192 ACL injuries of which 9.5%
resulted in permanent disability discharge. The authors noted
a multifactorial risk profile in which psychosocial factors
were strongly associated with disability discharge.34
Return to full duty may be used in the military population as
a marker of success after ACLR. Our goal in the present study
was to further define functional limitations among military per-
sonnel after ACLR. Although high success rates are generally
reported after ACLR, our experience at a large military post
with a high deployment tempo revealed that a large number of
soldiers experience permanent activity limitations precluding
full return to duty. The incidence of permanent military activity
restrictions after ACLR has not been previously reported to our
knowledge. In this study, we sought to evaluate endpoints
including medical board (medical discharge) and permanent pro-
file (PP; permanent activity restriction while remaining on active
duty) among soldiers who underwent ACLR. Additionally, we
sought to identify risk factors for soldiers proceeding to PP and/
or medical board after ACLR. We hypothesize that younger
age, lower rank, smoking, concomitant meniscal/chondral
injury, use of allograft, and smaller graft >8 mm diameter
will increase the incidence of PP and/or Medical Evaluation
Board (MEB) after ACLR in service members.
METHODS
Study Design
A retrospective review was used to determine return-to-duty
outcome among soldiers who had previously undergone
ACLR. The primary endpoints evaluated were PP and medical
board. PPs are chronic activity restrictions that meet military
retention standards for their Military Occupational Specialty
(MOS). A PP that does not meet military retention standards
will initiate a MEB, which results in separation of the service
member from the military. Retention standards and policies
regarding profiling procedures are detailed in military regula-
tions. The study was approved by the Institutional Review
Board for database access before performing data collection.
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Participants and Data Collection
All active duty service members who underwent primary
ACLR at our army institution during the time period from
January 1, 2005 until December 31, 2010 were considered
eligible for the study. Surgical patients in a dependent or
retiree status were excluded. Other exclusion criteria were
revision ACLR, multiligamentous knee reconstructions, con-
comitant knee osteotomies, concomitant allograft meniscal
transplantations, etc. Of note, patients who underwent pri-
mary ACL during the study period but then went onto
require additional surgeries later (i.e., revision ACL) were
included in the study population.
Candidates for the study were identified using the Surgery
Scheduling System (S3) during the study period. The elec-
tronic medical record and operative reports were then analyzed
to collect pertinent demographic and surgical information
including age, gender, MOS, tobacco use, rank, associated
injuries, graft type, graft size, graft failure, and subsequent sur-
geries. The MOS was utilized to classify soldiers to noncom-
bat or combat arms according to U.S. Army Organizational
Doctrine. Finally, the return-to-duty endpoints including PP
and medical board were recorded. The electronic medical
record system, Armed Forces Health Longitudinal Technology
Application, was implemented in early 2005 at our facility,
and subsequently, data from surgical patients before 2005
were not readily accessible for the purposes of this study. The
electronic medical record for each identified patient was
reviewed to determine medical board and PP status.
Statistical Analysis
Categorical data were summarized using percentages and
Chi-squared tests or Fisher’s exact test, whichever is most
appropriate. Means and standard deviations or medians and
interquartile ranges were used as summary statistics for con-
tinuous variables and were analyzed using Student’s t-test
and analysis of variance or Mann–Whitney’s U-test as
appropriate. Significance for results was established when
p-values were less than 0.05. All analysis was performed
using JMP v. 10.0.
FINDINGS
A total of 470 patients met inclusion criteria for the study.
There were 41 women (8.7%) and 429 men (91.3%), with a
mean age of 28.5 yr (range 18.8–48.6 yr). Of the total
patients, 466 (99.1%) served in the army, whereas 4 (0.9%)
served in the Air Force. Of the 470 patients, 149 (31.7%)
were less than 25 yr at the time of surgery, 189 (40.2%)
were between 25 and 30 yr, whereas the remaining 132
(28.1%) were more than 30 yr. Of the total population, 199
ACLRs (42.3%) were performed on service members in a
combat arms MOS, whereas the remaining 271 ACLRs
(57.7%) were performed on service members in a noncombat
arms MOS. All airmen were forward air controllers assigned
to assist combat units and therefore assigned to combat
MILITARY MEDICINE, Vol. 183, January/February 2018
 Return to Duty following ACLR

TABLE I. Demographic Data TABLE II. Subsequent Procedures Following Primary ACLR in
Active Duty Military with Total Number of Patients for Each Type
Gender of Subsequent Procedure
Male 429 91.3%
Female 41 8.7% Total
Age 1. Revision ACLR 54
Under 25 yr 149 31.7% 2. Meniscal debridement 33
25–30 yr 189 40.2% 3. Irrigation and debridement 19
Over 30 yr 132 28.1% 4. Hardware removal 12
MOS 5. Meniscal repair 7
Combat 199 43.4% 6. Manipulation under anesthesia 6
Noncombat 271 57.6% 7. Microfracture 5
Rank 8. Meniscal allograft transplant 5
Junior enlisted 253 53.8% 9. High tibial osteotomy 4
Senior enlisted 179 38.1% 10. Autologous chondrocyte implantation 4
Junior officer 22 4.7% 11. Collateral ACLR 3
Senior officer 16 3.4% 12. Excision (plica, loose body) 3
Armed Service 13. Chondroplasty 3
Army 466 99.1% 14. Osteochondral autograft transplant 2
Air Force 4 0.9% 15. Neurectomy 1
Tobacco use Total procedures 161
No 193 41.1%
Yes 277 58.9% Note: 108 patients underwent a total of 161 subsequent procedures.
Grafts
Autografts 318 67.7%
Allografts 152 32.3%
Graft size
Less than 8 mm 154 32.8%
Greater than 8 mm 316 67.2%

arms. The patient breakdown by military rank included 253 PP Only

junior enlisted (E1 PVT-E4 SPC, 53.8%), 179 senior
enlisted (E5 SGT or higher, 38.1%), 22 junior officers (O1
2nd LT-O3 CPT, 4.7%), and 16 senior officers (O4 MAJ+
and warrant officers, 3.4%). Of the 470 patients, 193
(41.1%) who underwent ACLR used tobacco, whereas the
remaining 277 (58.9%) did not use tobacco (Table I).
Of the total number of patients, 152 (32.3%) underwent
ACLR via allograft, whereas 318 (67.7%) underwent ACLR
via autograft. Of the autograft group, 36 ACLRs (7.7% of
total) were performed via bone-tendon-bone and 282
ACLRs (60.0% of total) via hamstring; 64 patients (13.6%)
went onto failure of the ACL graft as defined by radio-
graphic tear confirmed by clinical exam. This included 34/
282 autograft hamstring (12.1%), 3/36 autograft bone-
tendon-bone (8.3%), and 27/152 allograft (17.8%). Of the
470 patients, 316 (67.2%) received grafts greater than 8 mm,
whereas 154 (32.8%) received grafts that were less than or
equal to 8 mm; 108 patients (23.0%) required subsequent
surgery (Table II).
Of the total number of patients, 247 (52.6%) required a
PP restriction and/or a medical board following surgery; 194
(41.3% of total) required PP; and 118 patients (25.1% of
total) required medical board. However, 65 patients (13.8%
of total) required both PP and medical board. Of note, there
is an overlap between these categories as some patients
failed a trial of activity restrictions and subsequently
required medical board. See Figure 1 for breakdown of mili-
tary career outcomes. Of the 41 females who underwent
129 (27%)
Full Return
223 (47%)
MEB Only
53 (11%)
Both
PP and MEB
65 (14%)
FIGURE 1. Military career outcomes following primary ACLR. Total
number or patients and percentages reported of patients who return to full
duty without restrictions, patients who received only permanent profile (PP),
patients who receive only medical board (MEB), and patients who receive
both permanent profile and medical board (Both). Note only 47% full return
to duty.
ACLR, 27 patients (65.9%) went onto PP and/or medical
board compared with 51.3% of males; however, this was not
statistically significant (p = 0.07). Age, smoking, rank, graft
type, and graft size were not found to be significant predic-
tors for subsequent PP and/or medical board. See Table III
for comparison of patient demographics with and without
military restrictions after ACLR.
Both ACL graft failure and subsequent surgeries were
found to be statistically significant predictors for PP and/or
MEB (p < 0.0001). When PP and MEB were evaluated as

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 Return to Duty following ACLR

TABLE III. Comparison of Patient Demographics in Patients with and without Military Restrictions After ACLR

No Restrictions PP and/or MEB Total p

Sex, n (%) 0.07
Male 209 (48.7) 220 (51.3) 429
Female 14 (34.1) 27 (65.9) 41
Age at surgery, n (%) 0.46
>25 77 (51.7) 72 (48.3) 149
25–30 86 (45.5) 103 (54.5) 189
>30 60 (45.5) 72 (54.5) 132
MOS, n (%) 0.03
Combat arms 106 (53.3) 93 (46.7) 199
Noncombat arms 117 (43.2) 154 (56.8) 271
Tobacco use, n (%) 0.44
Yes 87 (45.3) 105 (54.7) 192
No 136 (48.9) 142 (51.1) 278
Rank, n (%) 0.27
Junior enlisted (E1–E4) 114 (45.1) 139 (54.9) 253
Senior enlisted (E5+) 88 (49.2) 91 (50.8) 179
Junior officers (O1–O3) 11 (50.0) 11 (50.0) 22
Senior officer (O4+)/Warrant 11 (68.8) 5 (31.2) 16

Total number of patients and percentages reported for each demographic category with and without military restrictions. p-Values reported in far right column for
each demographic category. Note for MOS category that noncombat arms soldiers were more likely to require PP and/or MEB than combat arms soldiers.

TABLE IV. Comparison of Patient Surgical Characteristics in Patients with and without Military Restrictions After ACLR

No Activity Restrictions PP and/or MEB Total p

Meniscal tear, n (%) 0.02*
Yes 156 (51.5) 147 (48.5) 303
No 67 (40.1) 100 (59.9) 167
Chondral injury, n (%) 0.75
Yes 57 (48.7) 60 (51.3) 117
No 166 (47) 187 (53) 353
Graft type, n (%) 0.33
Autograft hamstring 134 (47.5) 148 (52.5) 282
Autograft bone tendon bone 21 (58.3) 15 (41.7) 36
Allograft 68 (44.7) 84 (55.3) 152
Graft size, n (%) 0.69
>8 mm 74 (45.7) 88 (54.3) 162
≤8 mm 145 (47.1) 163 (52.9) 308
Graft failure, n (%) <0.0001
Yes 15 (23.4) 49 (76.6) 64
Autograft hamstring 34 (12.1)
Autograft bone tendon bone 3 (8.3)
Allograft 27 (17.8)
No 208 (51.2) 198 (48.8) 406
Subsequent surgeries, n (%) <0.0001
Yes 30 (27.8) 78 (72.2) 108
No 193 (53.3) 169 (46.7) 362

Total number of patients and percentages reported for each surgical category with and without military restrictions. p-Values reported in far right column for each sur-
gical category. Note for meniscal tear category that patients without a meniscal tear were more likely to require PP and /or MEB than patients with a meniscal tear.

individual endpoints, both ACL graft failure and subsequent
surgeries were still statistically significant. Neither concomitant
meniscal nor chondral pathology was found to be statistically
significant predictors for the study endpoints. In fact, patients
without a meniscal tear addressed at the time of surgery had a
higher likelihood for proceeding to PP and/or MEB than those
with a tear (p = 0.02). Medial meniscal debridement, medial
meniscal repair, lateral meniscal debridement, and lateral
meniscal repair were evaluated as individual predictors, but
none of those variables reached statistical significance. See
Table IV for comparison of surgical characteristics in patients
with and without military restrictions after ACLR.
Combat arms MOS was found to be a negative predictor
for PP and/or MEB. In fact, service members in a noncombat
arms MOS were more likely to proceed to PP and/or MEB
than those in a combat arms MOS (p = 0.03).

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 Return to Duty following ACLR
DISCUSSION
This study assessed the military career outcomes following
ACLR in active duty service members with two primary
endpoints: PP and medical board. According to our results,
military service members who undergo ACLR during active
duty have a high likelihood for postsurgical limitations as mea-
sured by these endpoints. In this study, 52.3% of patients who
underwent ACLR required PP and/or MEB during their post-
surgical course. These restrictions occurred irrespective of age,
gender, rank, smoking status, graft type, graft size, or concom-
itant meniscal/chondral injuries. Only ACL graft failure and
subsequent surgeries were found to be significant predictors
for eventual PP and/or MEB in this population.
Two previous studies by Cullison et al. and Edwards
et al. reported on military career implications following
ACLR with return-to-full duty rates of 69.9% and 77%,
respectively.32,33 We reported a medical board rate of
25.1%, which is consistent with the findings of both studies.
However, both of those studies concluded that full return to
duty was possible in the remainder of their population. Our
study suggests that many service members are not capable of
a return to full duty after ACLR and have permanent restric-
tions as reflected in a permanent profiling rate of 41.5%.
Surprisingly, only 47.7% of service members in this study
returned to full duty without restrictions. This difference
may be explained by numerous modifications and improve-
ments have been made to the military profiling system since
both studies were published. Now, an electronic profiling
system (eProfile) provides universal, dependable information
to medical providers anywhere in the world. This system
allows a more accurate medical assessment of each service
member’s clinical status and limitations. Additionally, these
studies were published before the Global War on Terror.
The deployment tempo significantly increased subsequently
across all military services, which served to increase physical
demands on the individual service member. The 47.7% rate
of return to full duty without restrictions in this study is con-
sistent with return-to-play rates recently reported by the
Multicenter Orthopaedic Outcomes Network consortium in
high school and college athletes.28 This serves to highlight
the functional limitations that active individuals may experi-
ence following ACLR across various sports and occupations.
We evaluated multiple related variables in this study as
they related to the career endpoints. Although we hypothesized
that younger age, lower rank, smoking, concomitant meniscal/
chondral injury, use of allograft, and smaller graft >8 mm
diameter may predispose a service member to PP and/or MEB
after ACLR, none of those variables were found to be signifi-
cant predictors for the career endpoints in this study. Cullison
et al. also found no correlation with age, rank, time from
injury to surgery, and KT-1000 measurements, although severe
chondromalacia did correlate with poorer results.33 Our find-
ings were not consistent with those of Edwards et al. regarding
older age and presence of degenerative joint disease.34 Only
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ACL graft failure and subsequent surgeries were found to be
significant predictors for subsequent PP and medical board in
this population.
Although the increased risk of ACL injury in female ath-
letes is well documented in comparison with males, a recent,
large meta-analysis by Tan et al. also described poorer post-
operative outcomes.35 Among 135 publications included in
their review, female athletes had inferior outcomes in instru-
mented laxity, revision rate, Lysholm score, Tegner activity
score, and ability to return to sports. In this study, 65.9% of
female soldiers required a PP and/or medical board follow-
ing ACLR, although this finding did not reach statistical sig-
nificance. With only 34.1% of females returning to full duty
without restrictions, this study reinforces the disproportion-
ate negative effect of ACLR on females versus males.
Interestingly, patients serving in a combat arms role were
less likely to proceed to PP and/or MEB than those in non-
combat roles. Additionally, individuals without a meniscus
tear were more likely to require PP and/or MEB than those
with a meniscus tear. Although these findings are difficult to
explain, they may highlight that multiple factors, including
psychosocial issues, may influence an individual’s ability to
return to the same level of activity as before injury. Positive
psychological responses and coping mechanisms such as
motivation, confidence, and low fear have been associated
with return to preinjury level of participation and sport.36
Combat arms units often add a camaraderie/bravado and a
warrior ethos that may cause soldiers to feel that they are let-
ting their units and battle buddies down if they do not return,
which is less often seen in noncombat units. A retrospective
study by Enad et al. on 169 primary ACLRs and 19 revision
ACLRs on special operations soldiers reported 92% and
90% return to duty, respectively, among a military popula-
tion with perhaps the highest functional demands.37 Soldiers
serving in combat arms have skills and training that are less
marketable and translatable into the civilian workforce as
noncombat soldiers. Also worth consideration during this
time period is that women were only allowed in noncombat
units and the post-studied has mechanized units that allow
soldiers to ride into battle instead of walking, both of which
could have variable impact on our results. Clearly, return to
full activity and sport following ACLR is a complex, multi-
factorial process requiring more research to identify modifi-
able risk factors, especially in the military population.
This study was conducted in a single institution involving
a large number of surgeons, a variety of reconstructive tech-
niques, and a number of different grafts. We were not able to
report functional outcome scores or laxity measurements due
to the transient nature of the military population, as the
majority of this population was relocated away from our
facility. Additionally, the decision to place a soldier on PP or
initiate a medical board is a subjective decision typically at
the discretion of the operating surgeon. This decision may be
based on numerous factors including subjective complaints,
e87
 Return to Duty following ACLR
objective clinical findings, lack of confidence on the extrem-
ity, and individual military career issues. We anticipate that
the return-to-full duty rate may be even lower than reported,
as some patients leave active duty early in their postoperative
course following completion of their military obligation or
disciplinary actions. Subsequently, these patients never reach
the decision-making point for initiation of a medical board or
PP, which typically occurs about 1 yr following index ACLR,
and summarily are considered full return to duty. On the other
hand, a small portion of patients have already been placed into
PP or MEB process before undergoing ACLR. Even if surgery
is successful, these patients are not considered a full return to
duty based on their preoperative status.
This study examined the return-to-full duty rates among
the active duty military population after ACLR. More than
50% of active duty military members who undergo ACLR
require permanent activity restrictions and/or removal from
active duty service. Those patients who experience ACL
graft failure or undergo subsequent surgeries are more likely
to require PP and/or MEB. Age, gender, rank, smoking sta-
tus, graft type, graft size, and concomitant meniscal or chon-
dral injuries were not determined to be significant risk
factors in this population. These findings allow for preopera-
tive discussion of the possibility that an ACL tear even when
reconstructed can lead to permanent military activity limita-
tions and MEB.
PREVIOUS PRESENTATIONS
Ivan J. Antosh, MAJ, MD, Jeanne C. Patzkowski, MAJ,
MD, Adam W. Racusin, MD, James K. Aden, PhD, Scott
M. Waterman, MD. Return To Military Duty After Anterior
Cruciate Ligament Reconstruction. Paper Presented at:
Society of Military Orthopedic Surgeons. 57th Annual
Meeting; 2015 December 7-11; St. Petersburg, FL.
FUNDING
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
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