THE PROBLEM
Current research says:
- 14-33% of athletes retear their ACL after surgery in a non contact mechanism
- Only 51-65% of athletes were able to return to preinjury levels of participation
- Only 55% of athletes had been able to return to competitive sport at final MD follow-up
- 1 in 4 youth who tear their ACL will retear
1. Sandon et al., 2020 2. Schilaty et al., 2017 3. Wiggins et al., 2016 4. Ardern et al., 2014
MIGHT AS WELL FLIP A COIN
It goes without saying that if you are reading this then you or someone you know has suffered an ACL tear. And you know how disruptive this is in life, not to mention the heightened potential for for a career ending injury in sport, a significant decrease in performance, or a catastrophic re-tear. The above numbers don’t lie, and it is a symptom of our healthcare system’s mismanagement of properly rehabilitating our athletes back to 100% after an ACL reconstruction.
ACL TEAR BACKGROUND
The ACL is the main ligament that holds the knee together. It gets stressed when the knee is twisted and can rupture when strained under significant stress. A rupture of the ACL does not heel on it’s own. Left torn and unchecked, the ACL deficient knee puts the athlete at risk of future knee injuries, arthritis, ongoing pain, instability, and loss of time playing sport. If surgery is undertaken then extensive rehabilitation is needed usually requiring one year to recover.
Post surgical recovery focuses on the following generalized phases:
- Acute symptom management and graft protection: weeks 0-6
- Restoring range of motion: weeks 0-8
- Restoring normal gait: 4 weeks
- Ability to walk stairs: 6-8 weeks
- Progressive strength training: month 2-12+
- Power and agility training: months 9+
- Return to sport: months 9-12
TIME BASED RETURN TO SPORT
Many physicians and physical therapists rely on a time based strategy for return to sport following the above timelines to create generic protocols for their patients. This is based on the healing of the ACL graft and how long it takes to strengthen. If you put too much stress through the graft too soon, then it is at risk of rupture. There is truth to this and thus many physicians use this time based approach to allow their athletes to return to sport, stating a timeframe to return to sport at roughly 9-12 months. However, there are inherent problems with this approach. The time based return to sport philosophy does not take into consideration the full state of rehabilitation of the athlete. This is complicated by our insurance based medical system, rushing patients out the door in order to decrease costs, and feeds the mismanagement of global risk for future injuries when returning to sport.
Typical PT rehabilitation clinics emphasize restoring range of motion at the knee and if you are lucky they may guide a strength program and at the end of rehab look at jumping tasks prior to returning to sport. As the athlete progresses through this system and returns to their MD at 9 months, the doc looks at their calendar and gives the ok to return to sport. This outcome leads to the atrocious statistics above with high re-tear rates and poor restoration of performance. The problem with this time based approach is that it is not sensitive enough to catch important risk factors for heightened injury risk when returning to sport.
HEALTHCARE MISMANAGEMENT
Proper return to sport criteria needs to be objective, research based, and systematic in nature to look at the athlete organically throughout the continuum of rehabilitation. To do this rehabilitation experts need to not only focus their attention at the knee, but also need to look at the athlete’s movement as a whole.
- How does stiffness in the spine, hip, or ankles cause the athlete to change their movement with pivoting and twisting activities thus putting more stress on the ACL?
- Are balance deficits overlooked as normal for part of the rehab or does the clinician diagnose the root cause of the problem (vestibular, hip weakness, core weakness, pain, spinal nerve impingement, etc) and direct corrective exercises specific to the problem?
- Are there asymmetries in ankle, hamstring, or hip mobility?
- What is the athletes mental state of preparedness to return to sport and how does that influence their movements?
- What the relationship of core stability and knee function, how do the rehab specialists diagnose deficits and then provide corrective strategies?
There are so many variables that the rehabilitation specialists needs to look at it can be overwhelming. Insurance based rehabilitation clinics typically do not have the ability, the time, or the liberty to provide the athlete with all that is needed to properly prepare the athletes. Because insurance reimbursements are so poor the offices need to see more patients to meet their bottom line, detracting from the care that is needed. Unfortunately, this leads our rehab specialists to focus their care on the most important items post surgical and deferring/ignoring items that they are unable to dedicate their time to.
“We need to focus your therapy on restoring your range of motion in the knee during our sessions. You have the rest of your life to get stronger and you can do that on your own at a later time.”
Common PT to patient discussion during ACL rehab
This is how things like strength, balance, core strength, mobility deficits, and global movement patterns are ignored during rehab of the athlete.
SYSTEMATIC TESTING & INTERVENTIONS
To best manage the myriad of problems in returning the athlete back to sport the rehab specialist needs to follow a system that is objective and offers checks and balances for all the realms of movement. Once such system is promoted by Functional Movement Systems. In this system the injured athlete undergoes a Selective Functional Movement Assessment which looks at baseline fundamental movement and corrects the underlying problems. Once the athlete is out of pain and fundamental movement is normalized the athletes are taken through a Functional Movement Screen which looks at 7 essential functional movement patterns that are the foundation of sport movement. As the athlete progresses and wants to return to sport, balance at the end ranges of stability is tested using the Y Balance Test. Results from the Y Balance and Functional Movement Screen can be input into the Move2Perform software and readiness for return to sport and quantifiable injury risk can be calculated.
Following the above systematic testing or other similar rigorous systems we can assure the athlete has done everything in their power to manage the multitude of risk factors they face when returning to sport. Flipping a coin should not be tolerated when something as serious as an ACL tear occurs. Physicians and rehab specialists need to do better for their patients and patients should be alerted when all they hear is the time based approach for return to sport.
If you or someone you know has encountered this problem, please share your experience so we are all better educated on how to avoid the pitfalls of an ACL rehabilitation. And if you would like more information that is specific to your case, please: