Why Physical Therapy is Essential After ACL Reconstruction Surgery
Physical therapy is essential following an ACL injury and reconstruction surgery to regain function, strength, and mobility in the knee and return to sport safely. The ACL provides stability to the knee and controls complex motion of the knee. It is commonly injured during sports activities when an athlete makes a quick change of direction or speed with the foot firmly planted. ACL injuries are commonly treated with ACL reconstruction surgery followed by an extensive rehabilitation program. A physical therapist works with the injured athlete to regain function and strength in the knee before progressing the athlete through a return to sport protocol to ensure a safe return to sport and to minimize future re-injury of the ACL.
How ACL Injuries Occur
The ACL, or the anterior cruciate ligament, is made up of strong, fibrous material that provides support for its excessive mobility; the ACL provides stability to the knee. The ACL controls complex motion of the knee, detecting and responding to changes in direction, the position of the knee joint, and changes in speed and acceleration.
Non-contact ACL injuries are the most common and are caused by forces within the athlete’s body, such as a cut and plant action in which the athlete makes a quick change of direction or speed with the foot firmly planted. A direct contact ACL injury can occur when a force overcomes the tensile strength of the ACL, such as a helmet hitting the knee during a football game. Certain sports have a higher risk of ACL tears: soccer, football, basketball, and lacrosse. Symptoms of an ACL injury include pain, an audible pop in the knee, difficulty standing and putting pressure on the injured leg, swelling within 24 hours of injury, difficulty walking, and limited range of motion.
There are nearly 200,000 ACL injuries per year in the United States alone. Women have a 3 times higher risk of tearing the ACL. Experts suggest that female athletes have a greater incidence of ACL injuries than men due to differences in muscular strength, physical training, neuromuscular control, pelvic and lower extremity variations, increased ligament looseness, and estrogen’s influence on ligament characteristics.
ACL Reconstruction Surgery
ACL reconstruction (ACLR) surgery is typically recommended for athletes who wish to return to competition and to treat young, active populations. ACLR aims to restore the mechanical stability of the knee joint to be able to resume sports activities as quickly as possible and minimize the reinjury rate. ACLR replaces the ligament with a tissue graft, either from a cadaver or from the patient themselves (from the patellar or hamstring tendon). Various research studies have demonstrated that ACL reconstruction improved knee stability and allowed the majority of athletes to return to high-level sports competition. One study noted that 65% of the 100 patients studied who had undergone ACL repair surgery returned to the same activity level.
The risk of re-injuring an ACL that has been repaired is about 15% higher than the chance of tearing a normal ACL. Studies have noted that for athletes under the age of 25, between 23-29% will incur a second ACL injury, most often in the first year post-injury. To minimize this risk, a comprehensive rehabilitation program with a physical therapist and a thorough return to sport protocol is essential.
Physical Therapy for ACL Injuries
Physical therapy is essential following an ACL injury and reconstruction surgery to regain function, strength, and mobility in the knee and return to sport safely. After an ACL injury, ACL reconstruction surgery (ACLR) is performed as soon as possible. Early surgery is the gold standard in the treatment process. If surgery must be delayed, pre-operative physical therapy can play a critical role in preventing further deterioration of symptoms and improve pre-and post-operative physical function through an exercise training intervention.
Following ACLR, the athlete requires an extensive recovery time and a comprehensive rehabilitation program that can last from 9 months up to a year. Physical therapists design an individualized treatment program for each athlete based on the following phases of recovery and rehabilitation. The athlete is progressed along these phases at their own pace based on the physical therapist’s assessment of their readiness to move on to the next phase.
Phases of ACL Rehabilitation
Phase 1: Post-surgery, the physical therapist works with the athlete to manage pain and swelling in the knee. The therapist helps the patient begin basic strengthening of the muscles around the knee and works to regain knee range of motion. The therapist also helps the athlete contract the quadricep muscle early on to promote good knee extension and strength.
Phase 2: As the pain and swelling are reduced, the athlete can increase the amount of weight placed on the affected knee. The athlete is progressed to strengthening exercises, walking, stationary cycling, and balance training.
Phase 3: As the knee heals and grows stronger, the athlete can add in low-impact activities like light jogging, swimming, and gentle jumping exercises. The knee and the muscles around the knee continue to be targeted with strengthening exercises. By the end of this phase, the athlete can begin adding sport-specific training, although avoiding any cutting and pivoting motions at this time is recommended.
Phase 4: By this stage, the athlete can engage in functional sport-specific activities. The physical therapist guides the athlete through running, jumping, and agility training and sports drills and conditioning. The athlete is progressed to single leg plyometrics before moving on to the return to sport protocol.
Return to Sport Protocol for ACL Injury
A comprehensive return-to-sport (RTS) protocol is crucial to ensure that an athlete can safely return to competition and minimize the risk of re-injury of the ACL. Unfortunately, many use time as the sole criteria for readiness to return to sport. However, a functional, multi-test RTS protocol with a qualified physical therapist provides the best standard of care for athletes recovering from an ACL injury. An RTS protocol objectively measures an athlete’s progress and helps to determine the effectiveness of rehabilitation as well as when an athlete can safely return to sport without the risk of injury.
At Mangiarelli Rehabilitation, our sports medicine physical therapists utilize the BTE Primus RS testing equipment to test the isometric strength of the injured knee and non-affected knee. From there, our physical therapists guide the athlete through a series of tests to assess sports readiness and function: strength and joint stability by testing single-leg-based skills; speed, agility, and coordination tests; plyometric activities; and a running mechanic evaluation.
