ACL REHABILITATION: DO WE REALLY ‘KNEE’D’ TIMEFRAMES?
March 16, 2016. I rush from work to basketball training. We have just won our first game of the Premier League season the week before. I warm up on the sidelines and get straight into the trial game. The young, enthusiastic U18 state team is running a half court trap. I’m playing point guard, I get the ball over half court before being trapped by two players, I jump to get through the press and land awkwardly.. The sound will never leave my memory. I knew straight away what had happened… there goes my ACL.
In any athletes career it’s the dreaded three-letter word you never want to hear. It means surgery, around 9-12 months away from sport and a lot of rehabilitation. I’m writing to share my story, thoughts and shed some light from a physiotherapy perspective on rehabilitation.
In today’s society, it’s hard not to compare ourselves to others in all facets of life. We are exposed to so much information through social media and Dr Google. I’m guilty of it with my rehab. I was constantly asking other players who had gone through what I had, ‘When did you get off crutches?” “When did you start running?” There was a constant search for a magical timeline. I wanted to know how I was tracking in relation to the timeline, was I ahead of it or was I behind it – I (k)needed to know!
Which leads to my point… Why, in ACL rehabilitation, do we set timeframes for return to running, agility or sport?
Each and every one of us is different. I had a slow start to my rehab, I struggled to get my knee to fully bend, which meant it took a bit longer to get to the strengthening phase, but since then it’s progressed quite quickly. Others that I’ve treated have their range back straight away but lack the control to get back into running and need to be held back. Some are overall quicker through each stage; some are slower.
You don’t get your driver’s license because you’re old enough; you get it when you’ve shown that you are capable.
Initially rehabilitation protocols are based on tissue healing and the remodelling process of the graft – this tells us when we can apply for our license: our license to do weight-bearing exercise, our license to run, our license to hop and bound, our license to return to sport – but doesn’t necessarily tell us that we are ready and able.
To date, a lack of emphasis on quality of movement may explain why re-rupture of the reconstructed ligament occurs in 3-22% of athletes and 3-24% rupture the other ACL within the first 5 years (Paterno et al. 2012). The question that these statistics proposes is what can we do to determine a safe return to sport and reduce the risk of further injury.
Using functional, goal-based rehabilitation, which is patient-specific and allowing progressions once specific functional goals have been achieved is one logical way forward. The British Journal of Sports Medicine (2016) recently published an evidence-based clinical practice update supporting the use of goal-based rehabilitation. They provide an evidence summary consisting of three phases with goal-based progressions for ACL rehabilitation. Van Melick et al. (2016) also discuss the use of an extensive battery of tests for return to sport, which should include strength, hop and quality of movement tests.
With 35% of athletes not returning to pre-injury sports level 2 years after ACL reconstruction, not only does rehab have to have go further in quality, but preventative measures need to also be taken. We are trying to spend more time preparing athletes pre-season and better preparing them pre-game. At Good Physio, we conduct pre-season screening, which includes video analysis, to gain a better understanding of how an individual moves and identify potential risk factors. Something I wish I’d done!
Paterno, M, Rauh, M, Schmitt, L, Ford, K & Hewett, T 2012, ‘Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport’, Clinical Journal of Sports Medicine’, vol. 22, no. 2, pp. 116-121.
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, vol. 50, no. 24, pp. 1506-1515.