Return to Sport post ACL Injury
How can we as therapists strive to improve return to sport rates?
As demonstrated in our previous blog posts, it is clear that ACL rehabilitation is no mean feat. It takes patience, hard work, and after all of that, a return to sport is not guaranteed. However, it’s not all bad news. There are a few key points for both patients and therapists to focus on in order to optimise return to sport outcomes.
Number one – Quads are king/queen.
Getting your quads as strong as possible is arguably the most important thing to focus on for ACL rehab. A study done in 2016 (Grindem et al) showed just how important it is to achieve at least 90% strength compared to your uninjured side before returning to sport. They found that 33% of athletes who returned to sport with less than 90% strength experienced another knee injury within 2 years of returning. Furthermore, every 1% of side-to-side difference below 90% equated to a 3% increase of further knee injury over that 2 year period!
This means plenty of; squats, lunges, leg presses and bulgarians which are great exercises for building quadriceps strength. However, all of these exercises tend to easily allow someone who is rehabbing their knee to offload the quadriceps and compensate using other muscle groups. The knee extension exercise, when used at the right time and in the right range of movement, is the MOST optimal exercise for building quadriceps strength as it isolates the quadriceps muscle group.
A recent systematic review showed that open kinetic chain exercises (OKC) (when prescribed (i) after 6 weeks and (ii) in a reduced ROM of 45-90deg) did not increase ACL laxity at any follow up time point (Perriman, Leahy & Semciw 2018). Furthermore, full AROM knee extensions from 3 months post-op showed no increase in ACL laxity at long term follow ups (Fukada et al 2013, Heijne & Werner 2007).
The evidence consistently shows that you can introduce OKC exercises safely in full ranges of movement from around 3 months onwards and even earlier in restricted ranges. Yes, there is the argument that knee extensions may not be ‘functional’ but you can’t have function without basic strength!
Number two – Regularly perform objective measurements.
As the saying goes – ‘If you’re not assessing, you’re guessing!’ As clinicians it is crucial for us to know how our patients are tolerating and performing with our treatments, and when it is safe to progress them through the journey. There are a number of different objective tests, all with varying importance depending how far into the rehab the athlete is.
Initially there is a focus on settling the knee post surgery. Thus, pain scores, swipe tests for joint effusion and range of motion are important to reassess and track for progress. Strength assessments take major importance soon after, with a focus on knee extension, knee flexion, hip extension and plantar-flexion movements.
Depending on what equipment you have access to, there are additional methods to assess strength. Ideally, force plates and hand held dynamometers can be used to isolate different muscle groups for movements such as knee extension, knee flexion, hip extension and plantar-flexion. They can also provide more precise information such as kg of force produced, vs manual muscle testing which may differ between therapists and testers. Performance based tests are a simple and easy way to track strength with submaximal loads. These include the humble single leg squat, single leg bridge and single leg calf raise. Both testing techniques allow a direct comparison to the uninjured leg and can be used to determine readiness to return to running
Power based performance tests that involve hopping become increasingly important as the journey continues. Regaining full power in the injured leg takes time and measurements such as single leg hop for distance (horizontal power), single leg vertical hop (vertical power) and single leg side hop tests provide a solid base for power measurements. All three require minimal equipment and should be tracked, not only to measure progress, but to determine readiness to return to training/sport.
Finally, psychological readiness must be assessed with subjective questionnaires. Returning to sport after rupturing an ACL is incredibly taxing and many mental hurdles must be overcome along the way. Often an athlete will tick all the boxes physically, however still feels as though their knee may not be quite ‘right’ or there. It is important to flag this, as going into a game scenario with anything less than 110% intent could lead to further injury. The ACL-RSI and IKDC Subjective Knee Evaluation Form are great options to use with athletes.
Number Three – Do field sessions with your athletes.
Returning to running will be a big aspect of all ACL rehabilitations, especially for those athletes wanting to return to field based sports. With that in mind, being with that athlete when they perform their first jog can be incredibly rewarding. It often comes as a result of months of hard work, in particular from the client. Moving forward from here, it’s not as simple as just continuing to run more or run quicker, to get an athlete to meet the demands of their chosen sport.
During field based sports, acceleration, deceleration, max velocity, change of direction and agility are all examples of skills that need to be trained, much like strength and power in the gym. To successfully do this, athletes need to be observed by rehab professionals while performing these skills to be able to determine their tolerance to such drills. Identifying different strategies and inefficiencies to these drills can be important in finding the weak links in each individual.
Finding the time in your diary to take an athlete to the closest park can be difficult and there may not be a park that’s close by to your clinic. That’s okay! But it would be recommended to refer on to a rehab professional who does have the access and the capacity to do so. At the end of the day, we are a client-centred profession and need to act with their best interests in mind.
Number Four – Stay patient, it’s a marathon not a sprint!
With an estimated return to sport for amateur athletes of 12 months+, the rehabilitation of an ACL injury is one of the longest for sporting related injuries. As clinicians we need to keep our athletes engaged, motivated and ensure they have a clear understanding of what is required to return to sport.
Breaking up parts of the rehab journey into phases with differing sets of focused goals is a great way to ensure motivation stays high while both clinician and athlete remain on the same page. It is also important to celebrate these milestones; achieving full knee extension, the first run post injury, returning to team training and passing return to sport tests are all examples of important achievements that should be treated as such.
Likewise, taking short ‘breaks’ from rehab can be useful to help freshen up. This may involve a week or so off training or a period away from thinking about the rehab journey. Regaining strength and power can be a long and tedious battle for the athlete, both physically and mentally. This is more encouraged in the mid-later stages of rehab.
As always, we love to support our community in any way we can. If returning to sport following an ACL injury is something you are experiencing, please get in contact with us. We would love to support you on your journey!
Written by Jack Rains
— Physiotherapist, Sydney
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