ACL rehabilitation and return to play

Athletes who tear their ACL and want to return to their sport usually opt for surgical reconstruction. This is primarily done with either using the patient’s patella tendon or hamstring tendon to graft a new ACL. After surgery, patient’s need to perform rehabilitation in order to regain their range of motion, strength and function. Some reviews have been performed that can help guide the rehab and return to sport process. Interestingly, even though there has been a lot of research performed on ACL’s in general, there is not a lot of information on return to sport criteria.

For rehabiliation, the following has been recommended:

1. Forgo the brace. Post operative bracing is not effective for improving pain, range of motion or preventing a potential re injury and is not necessary.

2. An accelerate rehab is safe for patients and they can begin early weight bearing exercise, range of motion from 0-90 degrees and close chain strengthening exercising. Adding in eccentric quad strengthening after 3 weeks was also beneficial in recovery.

3. Focus on strength and range of motion. Adding neuromuscular strengthening is somewhat helpful, but the focus for rehabilitation should be on improving strength and range of motion. Once this is restored, neuromuscular training can be helpful to relearn movement patterns.

4. Single leg cycling can be performed in order to maintain cardiovascular fitness.

Returning to sports?

1. Many athletes do not return to their previous level of sport participation, in fact, only 50% may return.

2. The decsion to return is multifactoral, but there is a general lack of evidence to determine the best testing criteria to signal return to play. In general, the decision to return is based on the following;

a. Higher quadricep strength

b. Less swelling

c. Less pain

d. Fewer episodes of instability

e. Low kinesiophobia (fear of moving)

f. Higher athletic confidence

g. Higher motivation

3. Part of the challenge is the psychological componenet of returning to sport. The fear of moving (kinesiophobia) may prevent some patients from returning. Patient’s that have more confidence have a greater chance of returning to their sport.

The current research shows plenty of gaps in following a standard program for rehabilitation and return to play, but patient’s and their providers can use what we do know to customize a plan.

Patient’s should start moving as tolerated shortly after surgery. They can walk as they are able and perform range of motion exercises and strengthening as tolerated progressing the intensity as they heal.

When their graft is healed and they have regained strength and motion they can add in neuromuscular training to improve movement patterns. This is also a good time to work on building up their confidnce in a controlled setting. Allowing them to get into a position can improve their confidence as the speed and force of the movement is increased.

Consistently working on the psychological aspect of rehab should not be ignored. Rehab is a chance to control the environment so that patient’s can gradually tolerate the load. As they improve, their rehab should adjust to mimic the functional tasks they will need to perform in life and on the field. Once they have reached their healing, they should re-integrate into their sport (once again in a controlled setting) and progressively increase their activity.

While there is a lot of flexibility in these guidelines, this can serve as a framework for the rehabilitation and reintegration process. Discussing the steps with the patients, their support groups and providers can help to get everyone on the same page and understand the steps required to resume their active lifestyle.

Czuppon, S., Racette, B., Klein, S. & Harris-Hayes, M. (2014). Variables associated with return to sport following anterior cruciate ligament reconstruction: a systematic review. British Journal of Sports Medicine, 48 (5). 356-364.

Kruse, L., Gray, B. & Wright, R. (2012). Rehabilitation after anterior cruciate ligament reconstruction. Journal of Bone Joint Surgery, 94 (19). 1737-1748.