ACL injury is one of the most common injuries in field sports. This injury requires long-term rehabilitation and commitment from the injured individual. ACL rehabilitation has been updated in recent years due to new findings in the research. This new evidence has suggested replacing delayed weight bearing and limited range of motion (ROM) with early rehabilitation incorporating weight bearing exercises (1).
Conservative Management of ACL Rehabilitative
ACL rehabilitation can take two forms either conservative or non-conservative management. Conservative management is suitable for a certain cohort of individuals typically those with sedentary lifestyles however many other factors should be considered before suggesting this management strategy. These factors include but are not limited to patient’s age, level of activity pre-injury, integrity and quality of ACL bundles and presence of mid substance ruptures. Conservative management is initiated with physiotherapy treatment including optimal loading, anti-inflammatory measures, activity modification and exercise therapy. However, if patient symptoms of pain and instability are not reduced after physiotherapy intervention ACL reconstruction is recommended.
Non-Conservative Management of ACL Rehabilitation
Non-conservative management or surgical management of ACL injury is termed ACL reconstruction. This involves replacing the torn ACL with a graft from a different part of the knee mimicking its functions. There are many different types of grafts including patella tendon, hamstring tendon, quadriceps tendon and allograft. The most common grafts are patella tendon and hamstring tendon. The grafts chosen are patient dependant which is based on multiple factors such as anatomical variations, occupation, lifestyle and other injuries. ACL reconstruction is performed arthroscopically (key-hole surgery).
This management strategy is typically divided into four stages. These are acute stage, pre-surgical stage, post-surgical stage and return to sport/activity. The acute stage is similar to the conservative management strategy where physiotherapy management is utilised to improve proprioception, strength, ROM and stability. The pre-surgical stage involves preparing the knee for surgery to ensure the best possible post operative outcomes. The main focus is on strength and proprioception while keeping swelling to a minimum. The post-surgical stage initial goals are terminal knee extension equal to opposite side, early weight bearing and a combination of open and closed chain exercises to increase strength. The return to sport stage goals vary dependant on the individual and the sport/activity they are involved in. It ensures that the individual is ready to return to sport/activity and should involve the physical and mental factors which determine their readiness.
ACL Rehabilitation Timeline for Return to Sport
One of the biggest misconceptions in ACL rehabilitation is the ‘9-month timeline’ indicating that at this point it is safe to return to sport with unrestricted training and a low risk of injury. This removes the individuality of a rehabilitation program. Recent research has emerged indicating that a criteria-based rather than a time-based approach is recommended (2). This includes the individual meeting certain goals relating to objective measures of strength, stability, ROM and functional performance. Based on the athlete meeting these goals, eventually sport specific training should be incorporated while monitoring for signs of pain and instability. The mental readiness of an athlete should be considered before returning to sport regardless of their physical capabilities. It is important to address the psychological barriers present with returning to sport. Therefore, the timeline of ACL rehabilitation differs from one athlete to the next and goals should be used to motivate athletes rather than timelines.
References
van Melick N, van Cingel REH, Brooijmans F, et al 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 2016;50:1506-1515.
Grindem, Hege, et al. "Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study." Br J Sports Med (2016): bjsports-2016.