Where Are We Now?
Anterior Cruciate Ligament (ACL) rupture has occupied a large portion of elite and amateur sporting injuries for decades. Discourse amongst the general population continues to support immediate surgical reconstruction followed by a lengthy return to sport timeframe. Thus, management of either surgical or conservative ACL ruptures necessitates robust rehabilitation protocols and a barrage of objective measures to meet the low return to sport levels and high recurrence rates.
Despite Australia hosting the highest rate of ACL reconstruction (ACLR) in the world, it is important to note the paradigmatic shift towards conservative management. Non-surgical intervention is associated with obvious reduction in surgical sequelae, accelerated rehabilitation and the capacity for ACL healing. The intervention of choice must therefore evaluate individual presentation, psychological status, and pre-operative risk factors to facilitate the greatest patient outcome.
Irrespective of conservative or surgical repair, the primary goals for rehabilitation are as follows.
- Restore knee function
- Address psychological barriers to return to activity participation
- Prevent further knee injury and reduce the risk of knee osteoarthritis
- Optimise long term quality of life
In the context of ACLR, prehabilitation commences in the pre-operative phase. Key outcomes during this phase include: no swelling, full active and passive range of motion (ROM) and 90% quadriceps strength symmetry. Insufficient knee extension and quadricep strength pre-operatively can result in deficits in ROM/strength and long-term return to sport capacity. Thus, early engagement with a Physiotherapist is recommended to restore knee function prior to further intervention.
Moving into the post-operative rehabilitation phase, evidence fails to elucidate superiority of supervised or non-supervised exercise-based treatment. Dependent on the individual, exercise program dosage varies from daily to 2-3 times per week which may be warrant clinical reviews every fortnight. Rehabilitation is structured hierarchically to ensure that key milestones are met, and any adverse outcomes are detected immediately.
Rehabilitation post- ACLR guidelines are consistent with those completed during prehabilitation. Immediately, patients should minimise swelling via activity modification, utilise cool therapy for pain, commence active and passive ROM and quadriceps loading. These should be assessed clinically by your Physiotherapist prior to moving into Phase 2 of rehabilitation which is centred on strength and neuromuscular training. Neuromuscular training incorporates balance and dynamic control for coordination. Advancements are made by altering the length, repetitions, speed, and surfaces at which the exercise Is completed. Strength and power-based training are tailored to meet the individuals future return to sport goals. This incorporates both unilateral and bilateral training and then taper to heavier resistance lower repetition exercise. Here your therapist will be looking at lower limb alignment, pelvic control, lower limb strength and repetition maximum strength. For patients with an autograft meaning a graft harvested from their own tissue, strength discrepancy and healing considerations at the donor location must be addressed.
End-stage rehabilitation necessitates as shift towards sport specific training centred on power, agility and building athletic confidence. This is where aforementioned objective assessments come into play. Testing should include isometric quadriceps strength, single leg hop test, triple single leg hops test and the subjective Knee Outcome Survey. Symmetry of 90% quadriceps and hop test should be present to minimise the risk of graft rupture or new knee injury.
As the individual successfully meets the battery of return to sport criteria a graded return to sport can commence. Entry level is typically non-contact or soft sport training followed by unrestricted training and then graded return to competition. It is vital that strength training is maintained during this time until full capacity is reached. Again, working closely with your Physiotherapist and coaches to ensure that loading remains gradually progressed regarding intensity and frequency minimises the risk of subsequent injury or reinjury.
Aside from the physical components of return to high level function or sport, psychological barriers may present during late-stage rehabilitation in both athletic and non-athletic populations. Physiotherapists may utilise a questionnaire such as the Anterior Cruciate Ligament Return to Sport After Injury scale to evaluate said barriers and facilitate further intervention if needed.
Whilst limitations exist regarding the efficacy of individual components of return to sport battery testing, we can deduce the importance of limb symmetry regarding quadriceps strength, single leg hop testing, graft site strength and balance and proprioception. Implementation of robust rehabilitation protocols ensures that therapists are providing the best opportunity for return to sport, optimal quality of life and minimising the risk of re-injury or associated knee injury.
Mick Hughes. Melbourne ACL Rehabilitation Guide 2.0. Evidence-based treatment program for anterior cruciate ligament (ACL) reconstruction rehabilitation.
van Melick, N., van Cingel, R., Brooijmans, F., Neeter, C., van Tienen, T., Hullegie, W., & Nijhuis-van der Sanden, M. (2016). Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. British Journal Of Sports Medicine, 50(24), 1506-1515. https://doi.org/10.1136/bjsports-2015-095898
Filbay, S., & Grindem, H. (2019). Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Practice & Research Clinical Rheumatology, 33(1), 33-47. https://doi.org/10.1016/j.berh.2019.01.018
ACL Surgery – No Longer Kneeded? – Physio Network. Physio Network. (2021). Retrieved 29 June 2021, from https://www.physio-network.com/blog/acl-surgery-no-longer-kneeded/.