Anterior Cruciate Ligament (ACL) injuries are a hot topic in sport and at the top of every athlete’s and therapist’s mind. In the literature, they are highly researched and debated and the work in this area of rehab has set a foundation for much of the return to sport criteria for other injuries.
ACL injuries can be devastating for athletes from a physical and mental perspective. They require extensive rehab with many time and criteria-based milestones. Their variability in treatment can range largely from conservative management to various surgical procedures using hamstring, quad, or allograft (cadaver). What makes them even more complicated is the concurrent injuries that one may sustain including MCL, LCL, meniscus or bone contusions.
So, what should you do if you think you’ve sustained an ACL injury? Firstly, it’s important to obtain the appropriate diagnosis. The injured athlete should set up an appointment with their physician or physiotherapist. The physiotherapist will perform a series of hands-on tests to determine the injured structures. If it’s determined that there is high suspicion of an ACL injury, they will likely refer you to a sports med physician. The sports med physician will proceed with an assessment and if appropriate, request some medical imaging such as an X-ray and MRI and a surgical consultation. You can complete your medical team by including a sport psychologist who will help you navigate some of the challenges after sustaining an injury and how to build resistance into your resurgence.
By now the athlete will be a clear diagnosis of the injury. To the athlete this might mean ‘ACL tear +/- meniscus, MCL, or LCL etc. To the rehab team it may mean something more specific like the extent of the tear, its location shape, and of any concurrent injuries. This sets the stage for the treatment plan and management approach for the rest of the rehab journey.
Most rehab will follow a 4-step recovery that is then further broken down into smaller more detailed steps. The 4 larger steps are 1) Prehab – restore and improve function 2) Early Stage- post surgery tissue healing 3)Mid-Stage – Tissue Integration-rebuild muscle and joint capacity 4) Late Stage- Return (Resurge) to sport. This framework, laid out by some of the leading researchers in the field, gives room for a lot of optimism. Each phase lays out clear criteria that should be met for the best outcomes.
Prehab, one of the most important, and probably the most neglected steps, is completed with a sports med physician or physiotherapist. In this phase, an athlete should be screened as a potential ‘coper’ or ‘non-coper’. This is done through a series of tests. Copers often can avoid being managed surgically, while ‘non-copers’ surgery may be important to stabilize the knee. One of the single most important rehab factors that predicts outcomes in ACL injuries is knee extension strength. Hence, a prehab program is designed to restore knee extension strength to within 90% of the unaffected side. Prehab programs also work through other important areas such as the ankle, hip, and trunk which are important for knee health and return to sport. Knee extension strength is typically measured by a therapist using a digital or mechanical dynamometer. This provided the athletes with clear objective numbers on their current strength and symmetry of their limbs. An effective prehab program should be at least 5- week 2-4x/week. For the ‘non-coper’ restoring knee extension, is vital for favorable outcomes. Interestingly, it’s been shown that following a 5-week prehab program, 50% of potential ‘non-copers’ were re-classified to ‘copers’. Meaning that their knee was functional enough and stable enough that following the prehab program they could reconsider surgery. These outcomes were not only obvious following the 5-week program, but the outcomes remained at 2 years following injury. The new ‘copers’ had the same results as the initial ‘potential copers’ and those that underwent surgery even at the 2-year mark, presenting a strong case for a prehab program.
So, what should a prehab program consist of? These prehab programs are usually facilitated and monitored by physiotherapists. Your physiotherapist will make special modifications based on specific considerations and monitor regularly to ensure favorable outcomes. The prehab program should consist of symmetrical, asymmetrical and single leg exercises, knee extension and knee flexion exercises in open and closed kinetic chain positions, gradual joint loading through stationary, unidirectional and multidirectional landing and jumping exercises, as well a functional stability exercises in symmetrical, asymmetrical and single leg positions. Finally, the program should incorporate some level of external perturbation training that challenges stability from external forces and requires the athlete to maintain stability.
The prehab phase of ACL injury is often skipped or missed. Patients too often go into surgery without the appropriate base to get favorable outcomes post-surgery. Many athletes and non-athletes alike miss the opportunity to transition from ‘non-copers’ to ‘copers’ resulting in less favorable outcomes. It is vital that all ACL injured athletes and non-athletes complete at least a 5-week pre-surgical prehab program and follow up screening to re-evaluate if surgery remains a viable option given their circumstances.
Need some help navigating the complexity of ACL rehab. Give us a call or book a discovery visit.
Radek Wiechecki
Physiotherapist
MScPT BScKin BScBio
The Lab – Rehab and Performance
References:
Buckthorpe, M., Gokeler, A., Herrington, L., Hughes, M., Grassi, A., Wadey, R., … & Della Villa, F. (2024). Optimising the early-stage rehabilitation process post-ACL reconstruction. Sports Medicine, 54(1), 49-72.
Buckthorpe, M., & Della Villa, F. (2020). Optimising the ‘mid-stage’training and testing process after ACL reconstruction. Sports Medicine, 50(4), 657-678.
Buckthorpe, M. (2019). Optimising the late-stage rehabilitation and return-to-sport training and testing process after ACL reconstruction. Sports Medicine, 49(7), 1043-1058.
Mitchell, A., & Gimpel, M. (2024). A Return to Performance Pathway for Professional Soccer: A Criteria-based Approach to Return Injured Professional Players Back to Performance. JOSPT Open, 54(7), 1-42.
Thoma, L. M., Grindem, H., Logerstedt, D., Axe, M., Engebretsen, L., Risberg, M. A., & Snyder-Mackler, L. (2019). Coper classification early after anterior cruciate ligament rupture changes with progressive neuromuscular and strength training and is associated with 2-year success: the Delaware-Oslo ACL cohort study. The American Journal of Sports Medicine, 47(4), 807-814.
Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2010). A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. journal of orthopaedic & sports physical therapy, 40(11), 705-721.