Every year, thousands of athletes tear their ACL and only have one goal in mind:
“I want to get back to playing”
That is a reasonable goal considering only 71% of athletes return to sport.
But I want to challenge your thought process throughout this blog. I want your main goal to transform from just playing again, to returning better than before.
Even though there are constant advancements in surgery and rehabilitation, ACL injuries have one of the highest re-injury rates in sport with some sources saying 30%; this likelihood is even higher with athletes <21 years old which is 50%.
Why are these re-injury rates so high? There are many factors which play into it, but the main reason is likely that athletes return to injury before they are ready. Now, what determines if an athlete is ready to return to sport?
In this blog, we will discuss goals throughout the process, and how we make objective decisions instead of letting timeline dictate our return to sport.
Instead of organizing ACL rehab by phases, let's organize by qualities you're trying to restore.
Focus on achieving full knee extension (knee straightening) ASAP! This can be very hard to get back during later stages, so this is a huge emphasis early on. Flexion (knee bend) is important but it is easier to get back than extension. Tibial rotation is one under-looked range of motion, specifically internal rotation, so don’t leave this one out.
After an ACL reconstruction, there is a phenomenon called muscle inhibition, which basically means the muscles are not contracting as well as they should. So initially, focus on muscle activation, particularly quadriceps. Modalities like neuromuscular electrical stimulation can be very helpful for this early on. We can then transition into strengthening each lower body muscle, especially the quadriceps. Make sure not to forget muscles at the foot/ankle and core as these are crucial for full body stability and are often neglected. When an athlete is cleared to return to sport, the gold standard for quadriceps/hamstring strength is >90% limb symmetry index, which is the strength difference side to side. For example, If an athlete is producing 180lbs of force with their on the non-operated leg, we would want the surgical leg to be >162 lbs. This can be measured with a dynamometer if your facility has one.
One category that is often left out of ACL rehab is the ability of the surgical limb to stabilize. Many clinicians will give their athletes simple exercises such as balancing on one leg, but they don’t progress farther than that. We need our athletes to not only balance with stationary tasks, but to be able to move, react, and stabilize without even thinking about it. After all, no one should have to think about their knee with every move they make, it needs to become second nature.
Building the ability to decelerate is crucial and is a prerequisite before any power/speed work. Let’s think about it for a second; if we are going to run or jump, we have to be able to land and absorb that force appropriately. Otherwise, we are placing more stress on the surgical limb.
Once we have the ability to decelerate, we can transition into our more intense return to sport progressions. Being able to change directions is a demand of every sport, so make sure to introduce this early on with stepping with turns and slowly progress speed, direction, and reactionary components until the athlete is performing more sport specific drills. The same goes for speed and power; start with band assisted plyometrics without weight. Then you can increase intensity and volume over time.
Undergoing an ACL repair is not for the weak. It is a long process (9 month minimum) where the athlete is not only building back their strength, but their confidence. Each step of the journey is a new one, and with that comes uncharted territory. Being unsure or afraid is a normal feeling, but just go back to your “why” and trust those around you. You are not alone.