One of the most common questions asked after an ACL injury is “when can I return to sport?”. It’s also generally the first question asked by parents, teammates, coaches and in the case of professional athletes, the media. All of this places increased pressure on the timeline of returning to activities.
In the professional sporting world, there has been a push for more extensive research into the most efficient and effective ways to get athletes back to sport as quickly and safely as possible. In reality, there is no given timeframe for when you’ll be able to return to sport. The pathway can be unpredictable, it depends on many factors as well as your own determination to complete rehab exercises at home.
We sat down with one of our Physiotherapist’s, our very own ‘knee god’, Rob Godbolt. Rob treats out of our Bowen Hills clinic and also works alongside an orthopaedic knee surgeon. He has an extensive understanding and experience providing expert pre and post-operative treatment for ACL injuries. His knowledge of return to sport protocols and programs is second to none having worked with many elite sporting teams such as being the State of Origin Queensland Maroons Physiotherapist for many years. We chatted with him and picked his brain about all things ACL.
The Basics of ACL Injuries
The anterior cruciate ligament, most commonly known as the ACL, is the primary stabiliser of the knee joint. Its located inside the joint and connects the femur (thigh bone) and the tibia (shin bone) together. It works to prevent the two bones from shifting during quick side-to-side, pivoting and twisting motions. Without an ACL (or with a deficient ACL) the knee joint can be unstable – especially during lateral (side-to-side) and twisting movements. So how does an injury to the ACL occur?
There are two main causes of an ACL injury that we can categorise into contact and non-contact mechanisms. A direct blow to the knee can force the joint inwards and beyond its maximum limit. The same can occur in a non-contact instance; where the knee endures a twisting motion that stretches the ligament past its rotational limit, resulting in a tear or rupture.
Operative vs Non-Operative Treatment:
In recent years, ACL rehabilitation, reconstructions and prevention have become some of the hottest topics in the sports medicine world. In Australia, the majority of ACL ruptures are generally managed with reconstructive surgery by an orthopaedic surgeon. But non-operative measures should also always be considered.
ACL injuries are classified into 3 categories; copers, modifiers and non-copers. Injuries are classified into these terms to best determine the right treatment pathway after injury. Rob explained each of these categories to us in detail:
A coper classification is given when the knee joint can essentially ‘cope’ and function without the ACL. Those who are classified as copers can choose a non-operative treatment pathway. They are mainly characterised as having good knee stability and have the ability to compensate well after injury. Following non-operative treatment, and progressive rehabilitation, some copers can return to preinjury sports activity levels.
In comparison, a non-coper classification is given to those that continue to have ongoing knee instability, such as recurrent episodes where the knee gives way. Knee instability can cause strain and stress on the other surrounding structures of the knee joint, putting them at risk of injury and potentially leading to the joint wearing out more quickly. Due to instability and episodes of giving way, non-copers are unable to return to preinjury level of play. For individuals in this category, surgery is recommended, especially for those wanting to return to sport.
Modifiers / Adapters
Those that sit in between the classifications of copers and non-copers are modifiers, also known as adapters. These cases in particular can cope with normal everyday activities but are unable to return to twisting or pivoting sports due to instability. Most would be able to participate in straight line, low-impact sports such as cycling or swimming. Those wanting to return to running, jumping, pivoting and contact sports will most likely require reconstructive surgery. Playing with a torn ACL could result in further injury to the surrounding knee cartilage and other ligaments of the joint as well as interfering with the ability to perform due to instability episodes.
The categorisation of copers, non-copers and modifiers is helped by using a series of hop tests, assessment of strength, a questionnaire on general knee function and frequency of instability (give way) episodes. In patients with the possibility of non-operative treatment (copers and some modifiers) a phase of early rehabilitation is recommended. After this, further evaluation is done to determine if continuing non-operative treatment is still a satisfactory measure to return to sport.
The Decision Making Process
For some patients, the decision-making process is made easy by the severity of their injury. As an example, a non-coper or an elite athlete is very likely to be recommended for ACL reconstructive surgery. But for some, the decision doesn’t come as easily. Determining which treatment option is most ideal should be a shared approach between the patient and practitioner. The practitioner should present both conservative (non-surgical) and surgical options. What also needs to be taken into consideration during the decision-making process is the patient’s needs, goals and expectations.
External situational factors also play a part in influencing decision making. Competition, time in season, playing status and role in the team can all affect the patient’s treatment decision. Added pressure to return to sport as quickly as possible can also be felt from teammates, coaches and parents – sometimes negatively affecting the decision making process.
Returning to Sport
In Australia, operative treatment for ACL injuries are generally managed with ACL reconstructive surgery. In this procedure a portion of tissue, commonly the hamstring tendon, is taken and used to create a graft in replacement of the injured ligament. Over time, and with strength and conditioning rehabilitation, the graft takes the place of the original ACL. It provides the knee joint with the stability needed to return to sporting activities.
Before surgery, you’ll likely undergo a period of pre-operative physical therapy. The goal is to reduce pain and swelling, restore full range of motion and strengthen the surrounding muscles for best results post-surgery.
Patients who undergo reconstructive ACL surgery and rehabilitation can expect to be looking at a return to sports timeline of about 10-12 months. However, it’s important that a return to sport approach is based on achieving the sport-specific tests, results and milestones rather than a time-based approach.
Just as post-operative patients go through rehabilitation, those who choose the non-operative pathway also do. Rehabilitation is considered the most crucial factor in the management of ACL injuries. The rehabilitation process is made up of many phases, with each phase progressing from the one before. The specifics of rehabilitation treatment plans differ for each individual, but generally, they’ll follow a structure like the following:
- Restoring range of motion
- Increase weight-bearing gradually
- Early muscle activation
- Developing strength
- Improving muscular power
- Building running tolerance
- Speed and agility training
- Return to training
- Return to play / sport
Knowing When You’re Ready to Return
So what determines someone’s readiness to return to sport? Or the better question is, when is an athlete safe to return to sport with the lowest possible risk of reinjury? An in-depth rehabilitation program aims to address deficits in neuromuscular strength and limb loading to prevent and reduce the risk of a second injury occurring. Phases of rehab are gradual and intertwined with assessments to ensure results reflect the demands that the sport requires. Return to sport testing looks at the functional performance of the knee and objectively measures the athlete’s readiness to return to play.
The emotional and physical effort, as well as the financial and time investment in recovering from an ACL injury, whether taking an operative or non-operative pathway, is significant. Therefore, preventative measures and ensuring the body is ready to return to a high level of activity is essential to overall long term health. Once the individual has achieved the outcome measures that appropriately meet the demands that their sport requires, then they can usually return to sport.
For an overview of return to sport assessments and tests, Rob recommends looking at this protocol developed by Randall Cooper.
It contains the Melbourne Return to Sport Score (MRSS), which is an assessment tool used to examine a patient’s readiness to return to sport following an ACL injury. The test comprises three main components:
- Clinical examination (25 marks)
- IKDC subjective knee evaluation (25 marks)
- Functional testing (50 marks)
At the conclusion of testing, patients receive a score out of 100. A score greater than 95 indicates a greater chance of returning to sport. Strength testing is also an additional measure undertaken on professional athletes to compare asymmetrical knee strength differences.
In our QSMC Testing Centre, powered by VALD Performance, we can gain these unique insights by comparing the differences between your injured and non-injured knee. This data accurately identifies weaknesses and neuromuscular deficits that help your practitioner make more informed decisions about your ongoing rehabilitation treatment and recovery timeline. If you would like to know more about our ACL testing, click through to our blog here.
Prevention of Injury and Re-Injury
ACL injuries are usually dreaded among athletes. They’re serious injuries that not only cause physical trauma, long rehabilitation times and an interrupted sports season, but they also have mental and financial consequences.
Not all ACL injuries can be prevented. Injuries that occur from contact, such as a forceful blow to the knee is an unforeseen accident and is hard to prevent and prepare for. ACL injury prevention programs are designed to enhance movement efficiency and reduce the risk of injury. These programs may differ in exercises and drills but will share the same focus which is improving flexibility, strength, balance, agility and landing techniques. Additionally, learning to move with good alignment will help to protect your knees during physical activity. For sports that involve pivoting and twisting motions, increasing the strength of the surrounding structures of the knee can help reduce injury by improving your ability to produce the necessary forces needed to hold your knee in a safe position.
If you’re looking for a program to get you started, Rob recommends the Netball knee and Fifa 11+ programs. Usually these programs are performed as a standard warm-up prior to every training session. It’s important to always follow program instructions.
Whether you’re a recreational or professional athlete, or have suffered an ACL injury in the past 2, 6 or even 10 years and are worried about your knee performance, come see our team for an ACL assessment. Getting on top of your troubled knee now will have drastic improvements later on in life; such as being able to live a happier, more pain-free and active lifestyle.