ACL injuries are one of the commonest injuries seen in athletes as well as amateurs. ACL rehabilitation has evolved a lot over the last few years. From immobilizing the knee for an extended period of time to accelerated rehabilitation characterized by early range of motion, progressive strengthening, and early return to sport, we have come a long way. Having said that, the failure rate post-ACL reconstruction surgery is still quite high (1). Although there have been instances of successful early returns to sport, current research suggests that we delay it at least up to 9 months post-surgery to prevent reinjury as well as failures (2). At the same time, it’s necessary for physiotherapists to curate a program which is successful not only in the initial phases but also in the later ones. It is important that the patient is given a program that replicates the demands of the athlete’s sport and subjects him to the chaos and unpredictability encountered in competition. The aim should be to not only bring the athlete or amateur to the level of function that he was previously at but also to increase his capacity above and beyond that which he was capable of earlier.
Early rehabilitation post-ACL surgery is focused on-
- Reduction of pain and swelling
- Restoring full knee range of motion, especially extension
- Maintaining patellar mobility
- Restoring normal gait pattern
- Improving neuromuscular control and proprioception
In addition to these, advanced rehabilitation should include the following-
- Training knee as well as proximal control in multiple planes-
In addition to treating the knee locally, emphasis should be on improving proximal control as well. Not only does this help in offloading the knee but also helps in developing proper neuromuscular activation patterns. One should progress to weight-bearing exercises to train the whole body as a whole and introduce Closed kinetic chain exercises early in the program. In addition to lower body exercises, one also needs to work on core muscles so that the athlete/client doesn’t develop any faulty patterns of muscle activation.Also, since non-contact ACL injuries occur due to a triplanar mechanism (hyperextension, femoral internal rotation torque, valgus force) one needs to train knee control not only in the sagittal plane with exercises like squats, deadlifts, etc. but also in the frontal and transverse planes with exercises like multiplanar lunges, star excursion reaches, curtsy squats, lateral hops, diagonal hops, etc. to prevent re-injury.
- Improving aerobic conditioning-
In addition to progressive strengthening, one needs to incorporate aerobic conditioning (3) as well in the program by introducing a walk/run program or HIIT circuits. This will help in enhancing lower body muscular endurance, gait and running patterns and progressive drills can help in improving aerobic capacity as well.
- Improving muscle strength and control in all types of contraction-
Quadriceps dominance has been known to be a factor in causing ACL tears, especially at near or full knee extension ranges. ACL programs should include exercises that prevent quadriceps dominance and enhance co-contraction between quadriceps and hamstrings such as squats with forward body lean, TRX squat, etc.In addition to traditional concentric training, training the muscles isometrically and eccentrically also helps in developing robustness, aiding in preventing re-injury.
- Subjecting the athlete/client gradually to actual sports demands of agility, landing, cutting, plyometrics, speed, etc.-
After the initial phases of rehabilitation are over, it’s not enough to be satisfied with the patient getting back to activities of daily living. The latter phases of rehab must include a transitional return to sports training phase before handing over the athlete to a strength and conditioning coach. During this phase, it’s important to conduct a needs analysis of the athlete’s sport and train the athlete in a sports-specific manner so that he gets used to and adapts to the demands of the sport. After a criteria-based progression to the next phase, the athlete is introduced to landing drills, agility, plyometrics, sprints, etc.
- Ensuring the psychological readiness of the athlete to return to sport-
Lastly, it is crucial that the athlete is not only physically prepared but also prepared mentally to return to sport. This can be determined by various tests LIKE Tampa Scale for Kinesiophobia or the ACL-RSI or the Return to Sport after Injury Scale (4).
- Prevention of reinjury by making sure an ACL injury prevention program is carried out-
It is highly recommended that athletes continue with an ongoing ACL injury prevention program whilst they play their sport which includes plyometrics, proprioceptive and strengthening exercises.References-1) Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med. 2012 Mar;22(2):116-21. doi: 10.1097/JSM.0b013e318246ef9e. PMID: 22343967; PMCID: PMC4168893.2) Beischer S, Gustavsson L, Senorski EH, Karlsson J, Thomeé C, Samuelsson K, Thomeé R. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther. 2020 Feb;50(2):83-90. doi: 10.2519/jospt.2020.9071. Erratum in: J Orthop Sports Phys Ther. 2020 Jul;50(7):411. PMID: 32005095.3) Almeida AM, Santos Silva PR, Pedrinelli A, Hernandez AJ. Aerobic fitness in professional soccer players after anterior cruciate ligament reconstruction. PLoS One. 2018 Mar 22;13(3):e0194432. doi: 10.1371/journal.pone.0194432. PMID: 29566090; PMCID: PMC5864031.4) Woby, Steve R., et al. “Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia.” Pain 117.1-2 (2005): 137-144.