Anterior Cruciate Ligament Repair (ACLR)

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Part 2 – The Three Phases of Rehab

As a student on hospital placements, more often than not my role was to ‘mobilise’ patients. In lay language, that simply meant helping patients to get up and out of bed, and if they could, go for a walk. As a student, I worked weekends in the local hospital where I’d completed my Orthopaedic placement and had my own Anterior Cruciate Ligament Repair (see ACLR – Part 1).

Although a surgical repair or reconstruction is common practice among sports people, LaTrobe University showed here that fewer than 45% of sports people return to sport following surgery, so having a repair is no guarantee of returning to previous activities. As the same article shows, how quickly a surgical repair occurs after a rupture does not change the functional outcome either, at least in some cohorts. Some athletes successfully return to sport without an ACLR. I’ve previously shared this case report published in the BJSM of a Premier League football player returning to play in less than 8 weeks following non-operative management. This challenges the common belief that a surgical repair is required.

In September last year I wrote a blog post here following two podcasts on the topic, and Physio Mick Hughes recently shared this link to a discussion regarding interdisciplinary management of an athlete’s return to play, in regards to our role as Physiotherapists in that process. Are we suitably equipped, on our own, to provide the required rehabilitation to get an athlete back to their pre-injury status and ‘game-ready’ so to speak? Should we be working with an Accredited Exercise Physiologist or Strength & Conditioning Coach? At what stage does patient management change hands between disciplines, if at all?

In Australia, the most common donor site is the hamstring tendon, as opposed to a bone-patellar tendon-bone graft, which as far as I know is the preferred donor site for surgeons in the USA. If the donor site for an ACLR graft is the hamstring, that can take 2 years to heal down to the bone! So there has been question whether it is appropriate for an athlete to return to play prior to complete resolution of that healing process.

I’ve listened to all 106 episodes of PT Inquest. Host Erik Meira has a special interest in the knee and ACLs in particular, so it’s been discussed on several episodes, 18 of them in fact: #’s 7, 12, 16, 19, 20,21, 29, 34, 40, 41, 45, 53, 57, 59, 68, 72, 73 & 88. Erik has discussed on more than one occasion, the biggest risk factors for re-injury following ACLR being a return to sport in less than 9 months. Dr Pappas said the same thing: “Almost nobody should be returning to sport before 9 months”.

I haven’t joined in on Mick’s discussion on LinkedIn, but I think it’s important to identify the difference between ‘Return to Sport’ (RTS) criteria and Return to Play (RTP). It may sound like semantics and I’m sure the two terms have been used interchangeably. The work from LaTrobe and the Mayo clinic highlights clear modifiable biomechanical factors which significantly increase risk of injury. Those risks factors are not clearing someone to their activity or sport i.e. ‘return to play’, they’re clearing someone as suitable to return to *training* for their sport. There’s a significant functional difference between having the physical competence to perform a controlled objective physical assessment in a Physio’s clinic room and being game-fit. It may be that someone has a 30% strength asymmetry in their quadriceps where less than 10% is considered the cut-off. Until that person has regained strength through a specific strengthening program, they would be unlikely to receive clearance to re-commence training sessions.

This is my opinion. I would suggest ‘Returning to Sport’ would be more appropriately called Return to Training. If 9 months is the minimum duration for a Return to Play, a sportsperson would need to recommence ‘training’ several months prior to that. It could take months to regain the muscular strength, muscular (and cardiovascular) endurance, and the motor-control which are negatively affected by the surgical procedure and subsequent recovery period.

I believe there are three phrases: (1) the post-surgical Return To Function – being able to perform activities of daily living independently without assistance, compensation, or unwanted symptoms, (2) Return To Sport – modifiable risk actors have been addressed with a specific exercise program and the risk is considered minimal, (3) Return To Play – the coach considers the individual to be match-fit and game-ready.

For those not returning to sports, there may be no need to progress past the first RTF phase because the four primary biomechanical risk factors have little impact upon their day-to-day need to work and live. Those people simply don’t need to be doing the neuromuscular training we would prescribe for a sports person to address dynamic knee valgus, quad dominance, trunk control and left/right asymmetry in power and strength. That’s not to say they wouldn’t be useful or that we wouldn’t encourage them to continue with a more general program which may indirectly address similar goals. Although we know that it will take many months for tissues to fully heal, someone may be functioning perfectly well with no symptoms within 3 months and have no further need for assistance. Time and normal physical activity will take care of the rest perfectly well on its own. Adopting the same approach with an active individual could well be a recipe for disaster.

For the sports person with the goal of returning to play, they first need to pass multiple Return To Sport criteria which address the known modifiable risks factors. Only then might we hand them over to someone else to address a more specific Strength and Conditioning phase, or back to their coach. The Return to Function and Return to Sport phases are the Physiotherapist’s domain. In my opinion, Phase 3 – Return to Play – is the domain of the S&C specialist and coach. It’s our job to get them ready to return to activity; it’s the S&C/coach’s job to get them ready to play. In an ideal world, that’s how I would like to see it work. If a Physio functions exclusively within a high-level sports setting, they could well be involved from start to finish. This is written from the perspective of a more typical high street Physiotherapy practice which doesn’t resemble an athletes coaching/training facility.

In my opinion, the average physio in private practice typically isn’t well equipped either in skills, experience, time, or equipment and facilities to take a high-level athlete through the Stage 3 – Return to Play. I’d happily admit to not feeling suitably equipped in 3 if not all 4 of those criteria, because that’s not what *I* do.

To re-cap, the goal of Phase 2 – Return to Sport – is to make it *safe* for an individual to begin their Return To Play phase.

There is potentially a 4-fold increase in risk of re-injury if the individual has not met all 6 TRS discharge criteria.

– Isokinetic testing (various angles)

– Running t-test

– Single hop

– Triple hop

– Triple crossover hop

Isokinetic machines (Erik Meira shared this example) cost many thousands of dollars and we don’t have one, or a hand-held dynamometer. As they’re considered the ‘gold standard’, even we at PRIDE are not fully equipped to say with certainty that someone does not have a significant measurable asymmetry in quad strength and must use a proxy measure to make that clinical judgement.

Following an ACLR, there is a large spectrum of potential input someone may receive from a Physiotherapist. There may also be several other people from different disciplines involved during the three phases of recovery and rehabilitation. As illustrated here and in Part 1, there is much debate about who does what, and when. More treatment is not better. That spectrum could range from zero input from a Physiotherapist (like my own rehab), to a very hands-on guided daily protocol for a professional athlete. If you’re not a professional athlete but still physically active, like me, you still probably wouldn’t ‘need’ much input. If you’re playing sports, you’ll need guidance through Phase two to address the modifiable risk factors for a successful Return to Sport.

If you’ve had an ACLR, we would be very happy to help guide you through the Return to Function and Return to Sport phases of rehabilitation and work with you to determine the most appropriate level of input you want or need to reach your physical goals.

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