Return to Sport after ACL Reconstruction
By Jamie Phillips (Physiotherapist)
If you have had an ACL reconstruction in the past year or two, and you are looking to return to sport, then you may have some anxiety and apprehension about whether you are ready to return to play or not. If you have not completed a correct rehabilitation program, not been cleared by a physiotherapist and if you are returning to a high risk sport (eg, netball, football, soccer, basketball, etc.), then you may be putting yourself at a high risk of re-injury.
Recent studies have provided further knowledge and insight into risk factors for re-injury upon return to sport. Previously 12 months has been the time around when athletes should be ready to return to sport, however recent research suggests 9 months is adequate time, BUT ONLY if certain strength, balance and agility goals are achieved. As Physiotherapists we use certain tests to determine whether someone is ready to return to sport, and giving them the least chance of re-injury. Simply waiting 9 or 12 months (excluding LARS grafts) without any rehab is playing Russian roulette, as an ACL graft normally takes between 2-3 years to reach full maturity, therefore returning to sport prior to this, you need to counteract this graft weakness with increased knee strength, neuromotor control, and balance/proprioception that only a well developed and planned rehabilitation program can provide. Basically, if you are post 9 months post your surgery and you can perform a series of hopping and balance tests to 90% your non-operative leg, and perform an agility ‘T-test’ in under 11 seconds then you will have around a 5-10% re-injury risk. If you cannot pass these tests then your risk of re-injury is 35-40%, like I said it’s like playing Russian roulette. If you don’t pass these tests then every month after 9-12 months post-op your risk of re-injury reduces slightly until full maturity of your graft which can take up to around 3 years. Even then, poor strength and neuromotor control will increase your chance of putting your graft at risk
Often in the clinic we see patients who have had multiple ACL reconstructions, and they put it down to bad luck, however when we quiz them on their previous rehabilitation programs, often they have had inadequate rehabilitation and they have returned to sport under prepared. Reaching these strength and movement goals is hard work, and takes full involvement from the athlete to achieve these goals, as well as continuing ongoing prevention exercise once return to sport has been achieved. Patients are often surprised to know that post ACL reconstruction, you are at higher risk of injuring your non-operated ACL also, this is due to the reduced neuromotor control post-surgery that effects both limbs, therefore rehabilitation needs to address both legs. Rehabilitation programs post ACL reconstruction should start with regaining range of motion, full gait and some strength initially, then should progress to increase strength, the resumption of running around 3-4 months post-op and building on neuromotor control, balance, hopping/jumping, change of direction, before finally sport specific exercises.
Certain athletes are also higher risk of sustaining an ACL injury. Adolescent females are 4.5x more likely to injure their ACL in a first time injury, and athletes under the age of 20 are higher risk of re-injury, and recent evidence has shown that 30% of ACL reconstructions will fail in patients under 18 years of age. This re-iterates the importance of well planned rehabilitation programs for these athletes, adequate testing for readiness for return to sport, as well as planning prevention programs for young athletes, especially females due to their higher risk. It should become common practice that young female athletes/sports team (netball, soccer) perform ACL/Knee injury prevention exercises in their pre-season and during their warm-up, and research tells us that this can reduce the chance of ACL injury by up to 68%. Sadly these programs have not yet filtered through to most amateur level sporting clubs, but with adolescent athletes in high risk sports such as netball, soccer and football, local clubs at all levels should be implementing these programs.
TOP TIPS FOR RETURN TO SPORT AFTER ACL RECONSTRUCTION
1– Start your exercises straight after your surgery as advised by your in-patient physiotherapist. Even pre-operative rehabilitation exercises have been shown to reduce risk of re-injury.
2– DO NOT STOP rehab once you start running. Often we see patients disappear at this time, however there are many goals still to reach to reduce re-injury rates, and these are much more important that just straight line running.
3– Just getting strong is not enough! These patients need to retrain change of direction, jumping and landing mechanics as they are altered post ACL reconstruction and are a common cause for re-injury if correct training/exercises are not performed.
4– Make sure you are cleared to play ONLY after passing a number of jumping, hopping, strength and balance tests. If you don’t perform adequate rehabilitation then you should wait for full ligament maturity to return to sport which can take up to 3 years, and you will still have a higher risk.
5– Prevention programs in the form of pre-season strength and in-season warm up exercises are a must, especially for younger athletes, to reduce the risk of first time and recurrent ACL injuries.
Our physiotherapist’s can help you with all of the above issues, as many of our physiotherapist’s have rehabilitated many ACL reconstrctions, including elite athletes and professional sports teams. There is always risk of re-injury when returning to sport after an ACL injury, however this risk can be greatly reduced with a well designed rehabilitation.
Written by Jamie Phillips (Physiotherapist)
References
Sugimoto, D., Myer, G.D., McKeon, J.M., Hewett, T.E. (2012). Evaluation of the effectiveness of neuromuscular training to reduce anterior cruciate ligament injury in female athletes: a critical review of relative risk reduction and numbers-needed-to-treat analyses. British journal of sports medicine, 46(14):979-88
Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., Risberg, M. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine, 50, 804-808
Kyritsis, P., Bahr, R., Landreau, P., Miladi, R., Witvrouw, E. (2016). 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. British Journal of Sports Medicine, 50 (15), 946-951.
Ardern, C.L., Taylor, N.F., Feller, J.A., Webster, K.E. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. British journal of sports medicine, 48(21), 1543-52