7 Steps to Safely Returning From an ACL Injury

A quick overview of what it takes to get back on the field after a torn ACL.

The definition of rehabilitation is "to restore to useful life, as through therapy and education…to restore to good condition, operation or capacity" (Thompson 1995). Rehabilitation is indeed easy to do badly, and difficult to do well. A technically excellent operative procedure can be undermined by poor rehabilitation and vice-versa, whereby an average operation can be complemented by expert rehabilitation (English 2013).

The Guardian newspaper in the UK proclaimed recently that while an ACL injury is potentially not career-ending for an athlete at the highest level it can possibly affect performance levels. Does one ever return to where they were in terms of play and performance? Think Zack LaVine of the NBA's Minnesota Timberwolves, Jabari Parker of the Milwaukee Bucks (twice suffered!), the much maligned and injury prone Derrick Rose of the Cavs, Adam Eaton of the Washington Nationals, Gronk, Adrian Peterson and arguably the greatest quarterback of all time, Mr Brady. Some have gotten back. Some have struggled. In sports that require cutting, jumping and pivoting, this little band of connective tissue in the epicenter of the knee is really important. The rehabilitation has to be exacting and spot-on.

ACL Injury

Athletes who have sustained an anterior cruciate ligament (ACL) injury often decide to undergo an ACL reconstruction (ACLR) with the ultimate goal and expectation to resume sport at the same level of intensity and performance.

Unfortunately, the proportion of athletes successfully returning to this optimal level of functional recovery is relatively low, while moreover, the rate of a second ACL injury has been reported in around 20 percent of cases after clearance to return-to-play (RTP) (Paterno et al., 2014; Dingenen and Gokeler, 2017). This is even more pronounced in younger athletes.

There are still questions as to the gold standard for the evaluation of RTP readiness from a mental and physical perspective post-ACLR, but an optimized criterion-based continuous and multi-factorial approach based on shared decision making, a biopsychosocial model of care and biomechanical and neuro-physiological adaptations seems to be the best way to succeed. It's important to bear in mind that although surgical techniques are crucial, rehabilitation plays a pivotal role in the optimal functional recovery no matter what type of graft or fixation was used for the ACLR (Della Villa et al., 2012).

The stages that must be taken into account for the rehabilitation process for an ACLR are:

  1. The resolution of localized pain, swelling and signs of inflammation
  2. The recovery of soft tissue flexibility and joint range of motion
  3. The recovery of muscular endurance and maximal strength (use Isokinetic testing)
  4. The retraining of balance, neuro-muscular control and joint proprioception (awareness in space); While the native ACL is a sensor, the graft is not, and once reconstructed the knee loses the sense of joint position. A new sense of joint kinesia needs to be re-built (Nagelli et al., 2016). This is where proprioception and balance exercise is at the heartbeat.
  5. Sports-specific on-field rehabilitation and return-to-training (prevention to be included; fitness testing- use of GPS, lactate threshold and Vo2 max tests)
  6. RTP with team
  7. Return-to-performance if all stars align

Pool and gym-based work and in the later stages, more sports-specific technical elements need to be gradually intensified and progressed until the player demonstrates the ability to return to training participation. Along with the recovery of basic attributes such as mobility, flexibility, fitness, agility and strength, the surgically repaired knee must also regain sport-specific neuromuscular control to help with optimising stability and control of the entire kinetic chain (Bizzini et al., 2012).

Furthermore, to minimize re-injury potential and to maximize the players' career, concepts of sport-specific injury prevention routines need to be incorporated into the regular training regime throughout and after the rehabilitation process. For more specific details feel free to contact me. We abide by this paradigm of care in our FIFA Medical Centre for Excellence, which is called Isokinetic.