Stages of ACL Rehabilitation

Australia has the highest incidence of ACL injury in the world. An ACL injury has considerable risk factors for limiting activity and sporting participation due to poor knee function and the development of OA. Concerningly ACL injuries also have high re-injury rates within a 5 year period in returning to sport.

At Perform we are passionate about providing elite, evidence based treatment and rehabilitation to our clients and athletes ensuring we optimize their knee function and give them the best opportunity to return to sport successfully and safely.

This is why we have compiled the best current literature to develop an evidence based criteria driven treatment and ACL rehab program. This program transitions a client from initial injury, surgery and return to play with integrated strength and sport specific testing to guide our clinical decision and rehabilitation progressions.

ONE: Prehabilitation

If you have ruptured your ACL it is understandable that you want to get it repaired as soon as possible. However, it is important to let the knee calm down and regain a good level of movement and strength before surgery.

A recent study has demonstrated that a five week program of pre-habilitation prior to surgery improved rate of return to sport and enhanced knee function, strength after two years post surgery.

The most important goals of the Pre-Op phase are:

  • Eliminate swelling
  • Achieve full range of motion
  • Regain similar strength in your quadriceps and hamstrings compared to the other side.

TWO: Do I Need Surgery?

What are my options?

Deciding whether to opt for a reconstruction or non-operative management needs to be a collaborative decision with the patient, physiotherapist and orthopaedic surgeon.

The broad objectives in management of ACL rupture should include;

  • Restore function to the knee;
  • Return to previous or desired level of activity and address psychological barriers in returning (whether that includes walking the dog or playing high level netball);
  • Prevent further or secondary injury to the knee;
  • Reduce the risk of knee osteoarthritis;
  • Optimise long term quality of life.

There are a few factors which should be taken into consideration when deciding upon which management pathway is best, this includes;

  • Age;
  • Goals;
  • Concurrent injury (such as an associated meniscus tear with ACL rupture);
  • General health (particularly associated surgery risk);
  • Success in prehabilitation phase;
  • Personal considerations such as time, occupation, family;
  • Ongoing episodes of instability.

What should I know about operative versus nonoperative management? 

There is unfortunately a lack of high quality studies comparing non-operative and operative management of ACL rupture.

There is currently one high quality study which compares the outcomes of rehabilitation with the option of delayed surgery, versus planned reconstruction followed by surgery. At two and five year follow up, both groups demonstrated similar outcomes with respect to pain, function, rate of meniscus surgery and quality of life (Frobell et al., 2013).

It should be noted however that 51% of patients initially managed nonoperatively eventually elected for reconstruction. In conjunction to this, the non operative group was advised not to return to pivoting sports and both groups were on average only moderate athletes. As such, this scenario may not be applicable to all patients presenting with ACL rupture.

There is some evidence that suggests that those who sustain a repairable meniscus tear in conjunction with ACL rupture have better long term outcomes when managed with reconstruction and meniscus repair (Korpershoek et al., 2020).

Within paediatrics, there is also evidence which suggests a higher likelihood of meniscus or cartilage injury without ACL reconstruction (Arden et al., 2018). Overall it is important that decision making is collaborative and centred around what is important to the patient. 

THREE: Rehab = Movement + Strength

Complete rehabilitation following ACL rupture is essential in order restore function and reduce re-injury risk into the future.

Recovery following ACL rupture can take some time to fully develop strength and power whilst retraining motor patterns needed for success. It generally follows a staged a approach from injury right through to return to play. Each stage has a series of hurdle requirements that permit progression to the next stage and eventually return to sport.

FOUR: When to Return to Play

Unfortunately up to 25% of ACL reconstructions re-rupture. As such, it is important to ensure each athlete is ready when approaching return to sport. Whilst there are no perfect methods to detect readiness, we do have a range of evidence based screening tools to ensure the risk of re-rupture is minimised at return to sport.

Key competency areas for return to play 

  • At least 90% symmetry of leg strength, particularly of the hamstring and quadricep.
  • Development of muscular power required for acceleration and jumping.
  • Symmetry of hopping and landing tests.
  • Psychological readiness as identified within patient reported outcome measures.
  • Development of chronic aerobic and anaerobic training loads relevant to returning sport.
  • Successful completion of sports specific training block

FIVE: Do ACL Prevention Warm Ups

Once you have returned to sport, it is important to continue some of the strength training commenced during rehabilitation to prevent re-injury. A comprehensive warm up is also a key component to assist in both primary and secondary ACL injury prevention. The FIFA 11, one of the more well known injury prevention programs has been shown to reduce 58% of total injuries and 58% of non-contact injuries.

A word from Your Physio

Mitchell has comprehensive experience in the field of Sports Physiotherapy and ACL management and rehabilitation and is a Senior Physiotherapist at Perform Physio + Pilates, located at 181 Upper Heidelberg Road, Ivanhoe. Mitchell’s approach to Physiotherapy is quite progressive, utilising his clinical assessment and diagnostic skills to identify the symptomatic and causative elements of a client’s condition and then implementing a combination of manual therapy, clinical exercise, and strength and conditioning to optimise recovery, performance, and overall wellness.

Whilst managing ACL injury can be seen as rather complex to navigate, a graduated and staged rehabilitation approach based on best evidence, your needs and athletic demands is the best way to succeed. If you have further questions in regards to your ACL injury or your rehabilitation feel free to call the clinic as we are always more than happy to have a conversation and advise you on the best first line of treatment and care.

Mitchell Walker
Post Grad. Cert. Sports Physio + B. Physio
Senior Physiotherapist

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