ACL Rehabilitation
Rupture and Reconstruction
We all know of the dreaded anterior cruciate ligament (ACL) injuries. This generally means the athlete’s season is over and a long year ahead of rehabilitation. This has both major consequences on both the individual and the team they are playing in. Unfortunately, ACL injuries with or without contact are the most common major knee injury in football. Many ruptures are non-contact injuries, which are caused from motions such as pivoting (twisting), changing direction, landing or a combination of the three.
Females have a higher risk of ACL rupture, with competitive female athletes in sports such as soccer or basketball, at a 3-5 times higher risk of injury, opposed to their male counterparts. Strength, size, hormonal changes and Q angles (hip to knee angle) are all notable factors for the higher risk of injury for female athletes.
Younger age is being increasingly recognised as a risk factor for anterior cruciate ligament (ACL) graft rupture and contralateral ACL injury after ACL reconstruction (2).
Rehabilitation
Most ruptured ACL injuries result in an ACL reconstruction. This consists of the removal of the damaged ACL, then a graft replacing the ACL. Most grafts are taken from alternative soft tissue structures (tendon/ ligament). Your Orthopedic surgeon will determine which surgical/ graft type is required.
Rehabilitation post ACL reconstruction is an extremely delicate process which should be completed as follows:
Surgical recovery from incisions;
Regaining movement and range of motion (ROM);
Neuromuscular activation of the muscles;
Building strength and regaining muscles mass, and returning to daily tasks;
Continuing to increase strength and muscle mass, returning to all prior activities;
Complete full rehabilitation for return to sport with dynamic movement and sports specific focus.
In the early stages of rehabilitation, the focus is on regaining full ROM, and neuromuscular activation. This involves making sure all the muscles around the knee are activating well and at the correct times throughout movements. One way this can be performed is in the pool, which allows a greater pain free ROM due to the buoyancy of the water. The increased resistance increases muscle activation.
As you progress through your rehabilitation, consistency is the key. Not just for returning to work and normal function, but is extremely important when looking at returning to your chosen sport. Most evidence suggests waiting a minimum of 6-9 months before returning to sport. This timeline depends on which surgical intervention was performed.
Key considerations include:
Allowing the graft ample time to strengthen;
Making sure the muscles and structures of the supporting joints are strengthened;
Making sure the graft is durable enough for the rigours of competitive sport;
The training can then become more sport specific.
In a recent article discussing the likelihood of ACL graft rupture, it was reported that there is a 50% reduction in the risk of knee re-injuries (all injuries, not only ACL) for each month that a return to sport is delayed beyond the 6-9 month period(1). Athletes who did not meet the discharge criteria before returning to professional sport had a four times greater risk of sustaining an ACL graft rupture (1). This is compared with those who met all six RTS (return to sport) criteria. Another risk factor for graft rupture is the hamstring to quadriceps strength ratio (1). Deficits were associated with an increased risk of an ACL graft rupture (1). For every 10% decrease in hamstring to quadriceps strength ratio there was a 10.6 times higher risk of sustaining an ACL graft rupture (1).
The importance of performing a comprehensive and well-structured rehabilitation is extremely important. Therefore, it is beneficial to be supervised by well trained and knowledgeable health professionals such as Exercises Physiologists here at START Training.
If you are looking for rehabilitation and strength and conditioning please contact William Holland at START Training on 3356 9119!
Check out William’s credentials at:
https://starttraining.net.au/about-us/will-holland/
By William Holland – Accredited Exercise Physiologist; Accredited Exercise Scientist
References
Kyritsis, P., Bahr, R., Landreau, P., Miladi, R. & Witvrouw, E. Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture. Br. J. Sports Med. bjsports-2015-095908 (2016).
Webster, K., Feller, J. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine; vol 44, issue 11, 2016.