Anterior Cruciate Ligament (ACL) rehabilitation and when is the best time to see an Exercise Physiologist?

An ACL injury can be a really horrible injury and happens a lot in contact ball sports but can also happen not participating in sport. After an ACL injury more than likely you would go see a doctor ( maybe a sports doctor) and there is a good chance he will do some tests on you around your knee to inform the course of action from there. If there is a suspected ACL injury you will be sent for some imaging to confirm the doctor's thoughts. 

There is more than one course of action for you to take and this is dependent on your goals and what you want to get back too, this is for you and your doctor/surgeon to discuss. 

We now know that an ACL reconstruction immediately following an ACL injury does not necessarily mean a better outcome furthermore surgery may not be the answer in individual cases as a favourable outcome can be achieved without surgery. Not to mention the option or ability to have surgery after trying rehabilitation alone first. 

As EP’s we can work with physios and the treating doctor or surgeon to provide care and a path for rehabilitation back to what you love doing!

What is the ACL and ACL injury? 

The ACL is a ligament in the knee that provides crucial stability to the knee joint. As seen in the picture below it is in the middle of the knee attaching from the thigh bone to the shinbone. The ACL prevents the shinbone from moving forward on the thigh bone. 

An ACL injury is a tear/rupture or strain of the ligament from some form of forceful impact that strains the ACL more than its current capacity.

Other injuries commonly happen with an ACL injury, some examples of these may be meniscus injuries, trauma to cartilage, some bone trauma, injuries to other ligaments and some trauma to the joint capsule itself. These other injuries also affect injury prognosis and rehabilitation. 

Rehabilitation

A major factor in ACL rehabilitation is that the process should be outcome based, rather than time based. This means the progression should be based on achieving outcomes that we understand mean readiness for the next phase. This means that specific and valid outcome measures are being used to track progress and guide rehabilitation. 

Furthermore the program for rehabilitation should be specific to the injured person, everyone's injury is different, everyone responds differently to treatment and everyone has different goals they want to achieve following injury or surgery. 

Phases of ACL rehabilitation 

There are 5 phases of general ACL rehabilitation: 

• Pre-op phase - During this phase the goals are to reduce or minimise effusion ( fluid or inflammation build up), maintain full range of movement and depending on what pre -operative looks like, to maintain 90% Quadricep symmetry. 
• Acute phase - During this phase the aim of rehab is again to reduce or minimise effusion  ( target = no effusion), get back to full range of movement and ensure sufficient Quadricep activity.
• Intermediate phase - During this phase the core treatment goals should be sufficient Quadricep control over a planted leg, 80% Quadricep strength symmetry with the unaffected limb and 80% hop test performance with the unaffected limb.
• Late phase - This phase the treatment goals are to achieve 90% Quadriceps strength symmetry, 90% hop test performance with the unaffected limb and progress functional skills and confidence to match the demands of the goal activity.
• Prevention phase - Maintain muscle strength and dynamic knee stability and manage load appropriately. 

Returning to sport?

A more sport specific rehab protocol is the Melbourne ACL Rehabilitation Guide 2.0, this protocol was created by specialist sports physiotherapists that have worked with Olympic teams and elite AFL, netball, soccer and rugby teams, they also do research in the knee rehabilitation space. This guide is very specific and is outcome based and can be tailored to individuals and their goals.

The  Melbourne ACL Rehabilitation Guide 2.0 is similar to your general ACL rehab however they have included a return to sport phase which essentially assesses your readiness to return to sport both physically and psychologically.  The phases are: Pre op, Phase 1 - Recovery from surgery, Phase 2 - Strength and neuromuscular control, Phase 3: Running Agility and landings, Phase 4: Return to sport, Phase 5: Prevention of reinjury. 

When is the best time to see an Exercise Physiologist (EP)? 

Well technically speaking you can begin rehab with an EP for the initial phases of treatment and throughout the whole rehabilitation process. This should be dependent on the experience of the EP dealing with ACL’s and known knee injuries.

However I would suggest seeing a physio for the early phases of rehab as generally they have more experience around ACL and acute knee injuries as acute muscle and joint injuries is what they specialise in. 

The best time to see an EP I feel would be either at the intermediate phase or the late phase of rehab, or somewhere in between. EP’s are well equipped to apply principles that govern strength and conditioning and apply these to rehabilitation as this is an EP’s role in musculoskeletal conditions or injuries. After all, the late phase and prevention phases of ACL rehabilitation are primarily strength and conditioning. This would all depend on the individual and the treating physiotherapists preference. All I will say is make sure you are getting sufficiently challenged and measured throughout the entire process and in particular the late stages. 

ACL rehabilitation is a long process, a long wait to get back to sport or the activity you enjoy! So make sure the process is worth it, you minimise any complications and reduce the risk of a re - rupture! 

If you need any help with your rehabilitation or want to know more please ask!

Izaac Boylan 
Accredited Exercise Physiologist.