Anterior Cruciate Ligament Rehabilitation

Phase by Phase journey from Injury to Return To Play Program

Dr. Mohamed Kassim

Athletes who wish to resume high-level activities after an injury to the anterior cruciate ligament (ACL) are often advised to undergo surgical reconstruction. Patients’ general expectations after ACL reconstruction (ACLR) are high, with 94% expecting a return to play (RTP) to the same level as before the injury (Feucht MJ et al 2016).

These expectations are in sharp contrast to the findings of a recent systematic review and meta-analysis, indicating that only 65% of athletes after ACLR returned to the pre-injury level of sport and 55% returned to a competitive sports level (Ardern CL et al 2014). 

If the athlete has the goal to RTP, all stakeholders involved (e.g. surgeon, physical therapist, coach, patient, etc.) in the RTP decision-making process should prioritise a safe RTP, i.e. a RTP with minimal risk of sustaining a re-injury and/or developing long-term complications such as OA (Ardern CL et al 2016). 

It is critical to remember that ACL surgery is only half the battle in returning to pre-injury activity level and an extensive period of rehabilitation is required. Unfortunately, only 5% of ACL reconstruction patients receive evidence-based rehabilitation guidelines following surgery (Grindem et al. 2018).

So let me go through the ACL rehabilitation journey based on the Melbourne ACL rehabilitation Guide which includes evidence-based approach that we utilise it with all our ACL patients. The Melbourne Guide adopts a criteria-based rather than a timeline-based approach to ACL rehabilitation, ensuring that athletes are truly ready to return to play after ACL reconstruction. The advantage of this approach is that it recognises that different people progress at different rates for a variety of reasons.

The Program has six phases (including a pre-op phase) to ensure a logical, systematic and safe progression of rehabilitation from initial preparation for surgery through to return-to-play. At the end of each phase, a battery of tests will determine your readiness to progress to the next phase of rehabilitation.

 

  Pre-op Phase: Injury Recovery and Readiness for Surgery

Although athletes will typically want to undergo surgery at the earliest opportunity to minimise time away from sport or activity, it is advised that athletes undergo a period of rehabilitation before surgery. This is not only the physical preparation but also the psychological preparation for a lengthy period of reduced sports participation post-operatively.

Recent research indicates that those who carry out a period of pre-operative rehabilitation focusing on the range of movement and strength have better outcomes than those who don’t (Kim et al. 2015). 

 

 Phase 1: Recovery from Surgery

The primary goal immediately after surgery is to get the knee straight as soon as possible, ideally within the first 2-3 weeks.

Other important goals include settling the swelling as well as initiating quadriceps muscle activation. These goals will generally be achieved through a gentle range of motion exercises, quadriceps setting exercises and regular icing, compression and elevation of the knee.

 

 Phase 2: Strength and Neuromuscular Control

Phase 2 accounts for a considerable portion of the ACL rehabilitation journey as the patient works to rebuild strength and control around the knee. The primary goals in this phase include regaining muscle strength, balance & co-ordination.

Quadriceps strengthening is particularly crucial in this phase, with research illustrating that for every 1% increase in quad strength symmetry there is a 3% decrease in reinjury risk (Grindem et al. 2016).

Typical exercises in this phase may include squats, step-ups, calf raises, balance exercises and non-impact conditioning such as walking, cycling and swimming.

It is vital that appropriate exercises are chosen and that your rehabilitation is appropriately progressed throughout this phase. For example, the quadriceps must be trained within restricted range limits for the first 3 months post-surgery while the ACL graft is healing (Luque-Seron and Medina-Porqueres 2016).

We need to ensure that all exercises are being carried out with correct technique, which is particularly important as research highlights that ACL patients often demonstrate compensatory movement strategies for as long as five months post-surgery (Sigward et al. 2018).

 

 Phase 3: Running, Agility and Landings

Given the fact that the majority of ACL injuries occur whilst running, twisting, jumping or landing, Phase 3 is a critical component of ACL rehabilitation.

Provided you have demonstrated the requisite strength levels in Phase 2, Phase 3 will seek to introduce impact forces such as running, turning, jumping and landing as you edge closer to returning to play.

Due to the demanding nature of these tasks on the body and knee joint, rehabilitation must be progressed slowly and carefully whilst listening to the body’s response throughout this phase. Again, the technique is vital in this phase particularly with respect to hopping, landing and cutting.

Exercises will begin as pre-planned runs, jumps and turns but in later stages will incorporate reactive agility drills and landings with perturbations, to prepare the body for the unpredictable and often chaotic demands of the sport.

Athletes are often guilty of stopping their rehabilitation at this stage once they are back running and are pain-free. However, it is fair to say that the later stages of rehabilitation are arguably the most important in order to reduce the likelihood of re-injury and to ensure a successful return to sport, as well as minimising the risk of osteoarthritis in later years (Thorstensson et al. 2004). 

 

 Phase 4: Return to Play

When implemented correctly, Phase 4 of rehabilitation should be highly individualised and begin to look quite similar to the athlete’s regular training activity prior to their injury.

Focus in this phase is placed not only in the athlete’s physical readiness to return to play but also their psychological readiness, which recent research is highlighting as increasingly important (Paterno et al. 2017).

As for the question as to when the person is ready to return to play after an ACL reconstruction, although we do not adopt a timeline-based approach we would be strongly aligned with current research suggesting a minimum of 9 months, ideally waiting approximately 12 months before returning to sport. A critical piece of research highlights that the risk of ACL re-injury was reduced by a staggering 51% for every month return-to-play was delayed until 9 months post-surgery (Grindem et al. 2016).

A battery of subjective and objective tests provide a criteria-based recommendation as to an athlete’s physical and psychological readiness to return to sport. Research highlights that 38% of those who failed return-to-play criteria suffered re-injury, in comparison to only 6% of those who passed (Grindem et al. 2016).

Unfortunately, it is impossible to prevent all injuries in sport, however, the physiotherapist will do everything possible to minimise this risk as much as possible. 

 

 Phase 5: Prevention of Re-injury

The final stage of the Melbourne ACL Rehabilitation Guide aims to mitigate the risk of ACL re-injury by incorporating an ongoing ACL injury prevention programme. Research shows that injury prevention programmes reduce ACL injury risk by 50% (Webster and Hewett 2018).

This programme will generally include strengthening, balance and plyometric exercises that are carried out prior to every training session and games.

Upon return-to-sport and inevitable discharge from the clinic, the physiotherapist can help implement an ongoing ACL injury prevention programme to minimise risk of re-injury in the future.

 

 

Reference

Feucht MJ, Cotic M, Saier T, et al. Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2016;24:201-207.

Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent 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 2014;48:1543-1552.

Ardern CL, Bizzini M, Bahr R. It is time for consensus on return to play after injury: five key questions. Br J Sports Med 2016;50:506-508.

Grindem H, Wellsandt E, Failla M, Snyder-Mackler L, Risberg MA. Anterior Cruciate Ligament Injury-Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study. Orthop J Sports Med. 2018;6(5):2325967118774255. Published 2018 May 23. doi:10.1177/2325967118774255.

Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL Cohort Study. Br J Sports Med. 2016;50(13):804–808.

Kim DK, Hwang JH, Park WH. Effects of 4 weeks preoperative exercise on knee extensor strength after anterior cruciate ligament reconstruction. J Phys Ther Sci. 2015;27(9):2693‐2696. doi:10.1589/jpts.27.2693

Luque-Seron JA, Medina-Porqueres I. Anterior Cruciate Ligament Strain In Vivo: A Systematic Review. Sports Health. 2016;8(5):451‐455. doi:10.1177/1941738116658006.

Sigward SM, Chan MM, Lin PE, Almansouri SY, Pratt KA. Compensatory Strategies That Reduce Knee Extensor Demand During a Bilateral Squat Change From 3 to 5 Months Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2018;48(9):713‐718.

Thorstensson CA, Petersson IF, Jacobsson LT, Boegård TL, Roos EM. Reduced functional performance in the lower extremity predicted radiographic knee osteoarthritis five years later. Ann Rheum Dis. 2004;63(4):402‐407. doi:10.1136/ard.2003.007583.

Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study. Sports Health. 2018;10(3):228‐233. doi:10.1177/1941738117745806.

Webster KE, Hewett TE. Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. J Orthop Res. 2018;36(10):2696‐2708. doi:10.1002/jor.24043

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