ACL Reconstruction Part 3: Later stage rehab and return to sport
Following on from our previous post, for best outcomes and a faster recovery, it is important to achieve good range of motion, strength and neuromuscular control at the knee. Later stages of rehabilitation progresses from this, slowly incorporating more strenuous activities and eventually more sport specific training.
The recovery timeline
6 - 9 weeks
At this stage, there should be full range of motion at the knee, without limitations of pain. There is a greater focus now on developing more quadricep strength using more functional exercises, and creating more balance in strength between the legs. Advance balance exercises can be incorporated, and greater resistance and speed can be used to increase aerobic fitness.
Example exercise: Lunge (1/4 - 1/2 range)
9 - 12 weeks
A direct follow on from the previous weeks, maintaining range of motion at the knee, and progressing strength, balance and aerobic training as tolerated.
Example exercise:Prone eccentric hamstring with band
12 - 16 weeks
During this stage, sport specific exercises are introduced to target further quadricep and hamstring strength, balance, and aerobic fitness. More dynamic exercises for agility can be included to improve body awareness, control, and change of direction ability.
Example exercise: Skipping
16 - 20 weeks
Exercises can be further progressed now to simulate more sport-specific and functional tasks. Introducing plyometrics which train the muscles to reach maximal strength in a short amount of time, vital in activities such as jumping. Agility is also a key focus, paying attention to proper footwork, speed and timing, and eventually including cutting and pivoting type movements.
Example exercise: Lateral hopping
At this time, there should be good levels of aerobic fitness, muscular strength, neuromuscular control and balance, and symmetry between the legs. Continue more sport-specific training and advance plyometric and agility training.
Example exercise: Single leg drop-jump
Returning to sport
In general, gradual return to sport tends to start at around the 6-9 month mark, if theres no pain or swelling, and good tolerance to the sport-specific training exercises. In saying so, up until 9 months following reconstruction, for every month that return to sport was delayed, there is a 51% less chance of re-injuring the knee. On top of this, several studies have shown deficits in muscular strength, neuromuscular control, balance and force production of the leg muscles, up to 2 years following an ACL reconstruction. In the first 2 years following return to sport, there is also up to 6 times more risk of re-tearing the ACL, when compared to healthy individuals.
To help guide the return to sport process, many return to sport criteria have been developed to assess an individual's physical readiness to return to their sport safely. Commonly used criteria include:
Quadricep strength within 10% of the uninjured side
4 single leg hop tests (single hop (A), triple hop (B), crossover hop (C), and timed hop(D)); with no more than 10% difference between sides
Despite the desire to return to sport as soon as possible, it is important to complete a structured rehabilitation program. Allowing for adequate time to recover, not returning to sport too early, and achieving specific criteria and goals at each stage of rehabilitation, helps to optimise the recovery, return to sport safely and reduce the chance of another ACL tear.
Barber-Westin, S. D., & Noyes, F. R. (2011). Factors used to determine return to unrestricted sports activities after anterior cruciate ligament reconstruction. Arthroscopy: the journal of arthroscopic & related surgery, 27(12), 1697-1705.
Cavanaugh, J. T., & Powers, M. (2017). ACL rehabilitation progression: where are we now?. Current reviews in musculoskeletal medicine, 10(3), 289-296.
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., & Risberg, M. A. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British journal of sports medicine, 50(13), 804-808.
Nagelli, C. V., & Hewett, T. E. (2017). Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports medicine, 47(2), 221-232.
Paterno, M. V., Huang, B., Thomas, S., Hewett, T. E., & Schmitt, L. C. (2017). Clinical factors that predict a second ACL injury after ACL reconstruction and return to sport: preliminary development of a clinical decision algorithm. Orthopaedic journal of sports medicine, 5(12), 2325967117745279.
Physiotherapy ACL Protocol
Fowler Kennedy Sport Medicine Clinic. London, CAN, 2015
Pictures obtained from Physitrack