What to expect following an anterior cruciate ligament rupture
Have you injured your ACL? Unsure what the best management plan is? Or has your rehab progress been lacklustre?
Because of our expert Melbourne CBD practitioners' ongoing involvement in ACL research, they are passionate about using their clinical experience to optimise patient outcomes.
Traumatic sports-related knee injuries such as anterior cruciate ligament (ACL) ruptures are unfortunately becoming more common in the young athletic population. More concerningly, the management of many ACL ruptures is varied, and that’s partly why we believe many ACL injuries have mixed outcomes.
We’ve put together a comprehensive guide on what to expect through your ACL rehab journey and what our strategy is to optimise our patients’ outcomes following their ACL injuries, including a recent success story.
How do you manage an ACL injury?
There are typically two treatment approaches to ACL injury; non-surgical and surgical.
Our engagement with ACL research and a world leading rehabilitation facility has informed our Melbourne CBD Physiotherapy and Sports Medicinetherapists that the best approach is individually tailored and contingent on patient symptoms and their goals determined in the initial consultation.
In Australia, surgical management is by far the most common route, but many people can have a successful outcome with a non-surgical approach.
Where do you begin?
In your initial appointment, we’ll first discuss:
- The team that will support you alongside physiotherapy (e.g. surgeons, psychologists)
- Your current symptoms such episodes of the knee giving way, locking, clicking, catching and swelling
- Type of sports and activities you wish to be involved in long term
- Your beliefs and preferences regarding surgery
Many patients may not know which course of treatment to choose, and this is completely normal. Most orthopedic surgeons will not operate on a swollen or de-conditioned knee. In line with the latest evidence, we normally suggest at least 8-12 weeks of pre-surgery rehabilitation to give you the best surgical outcome. This period is a great time to think about your treatment choices (e.g. surgical or non-surgical) as we work with you to address:
- Knee range of motion
- Strength adaptations following your ACL injury
If I choose surgery, what will rehabilitation look like and how long will it take?
Rehabilitation of ACL injuries is quite variable, lasting anywhere between 9-20 months. To give an exact timeline is impossible as the complexity of the injury and recovery varies between patients. When pressed for a timeline we give a broad range since rehabilitation is criteria-driven, meaning specific outcomes on movement, strength and reported symptoms are advised before progressing rehabilitation. Hence, some patients are straight forward, while others take longer due to complications and consequently pass rehabilitation criteria at a later date.
So what will rehabilitation involve?
To provide some insight to this process, one of our recent success patients, Kat Gallucci, returned to elite cheerleading following a hamstring graft ACL reconstruction 14 months ago.
Following surgery, Kat's main goals were to:
- Regain quadriceps (thigh) muscle strength
- Achieve full active knee extension and flexion (bending and straightening your knee)
- Walking without the use of crutches or gait aids
There are a number of ways these goals are achieved, through a mixture of exercise, manual therapy and patient education about “do’s and don’t” in the early post-operative phase of ACL rehabilitation.
In Kat’s case, early management began with regular post-operative guidelines from OrthoSport Victoria, gait retraining and swelling management.
Three months post-surgery
Three months after surgery, graft maturation (healing) is still occurring, but it is likely that this is where quadriceps strengthening will begin to ramp up.
Moreover, hamstrings, calves and gluteal muscle groups will be progressively loaded through both heavy isolated and compound movements. There are so many types of exercises that can be done here, which is why it’s so important to work with your physio within your individual timeline and limitations.
In Kat’s case, her program included lots of quadriceps, hamstring and targeted hip strengthening exercises, with additional proprioception (awareness of joint position) tasks performed daily. Exercises were progressed based on pain, swelling, range of joint motion and fatigability. These clinical considerations were applied using strength and conditioning principles throughout ACL reconstruction physiotherapy.
How do I know if I’m progressing? Measure, measure, measure!
One of the unique things about ACL physiotherapy is our understanding of measuring what matters during your rehabilitation, such as joint biomechanics and tissue response to load.
We incorporate VALD performance technology and Keiser pneumatic machines to measure strength of each lower limb muscle, and incorporate this with jumping and landing biomechanics to determine whether you have passed the necessary criteria to move forward in your rehabilitation journey. Our measuring technology gives us the ability to identify why you may have been struggling in your rehab, giving us the best direction to find effective solutions.
Throughout Kat’s rehabilitation, we identified key metrics that needed to be addressed through physiotherapy:
- Eccentric hamstring strength
- Optimised ratio of gluteal and hamstring strength
- Build and maintain calf strength
We measured and built Kat’s hamstring strength through the VALD Nordbord. Kat worked through this banded basketball nordic exercise to increase her perturbation load. Kat's jumping and landing biomechanics were also gradually progressed through a variety of exercises.
When can I start running after an ACL injury?
Return to running is often seen as an easy milestone to achieve. At Melbourne CBD Physiotherapy and Sports Medicinetherapy and Sports Medicine, we believe that a return to running must involve a comprehensive screen of both physical capability, and psychological readiness.
Too often we hear of patients coming to us for a second opinion because they are hampered by persistent low level pain and swelling while running. We believe that this partly fuels the higher risk for osteoarthritis later in life and poor return to sport outcomes. Hence, we take a pragmatic and robust approach to return to running that incorporates:
- Lower limb strength
- Self-reported function and psychological readiness via questionnaires
- Single limb jumping and hopping performance
Why do we take a robust approach to return to running criteria?
Did you know that simply moving from walking to a slow jogging at 2-3 m/s approximately doubles the joint forces inside your knee. This increases the surrounding muscle forces such as the quadriceps (~6 x bodyweight) and Achilles tendon/calf complex (4-6 x bodyweight) substantially. Therefore, it’s imperative that during your rehabilitation you are strong enough and exposed to higher impact forces in a controlled environment before beginning your return to running.
In Kat’s return to run rehabilitation, she was prescribed a series of plyometric drills, coupled with hopping and landing exercises in our Alter-G treadmill which enables us to modify the load applied to the lower limb. This was a much better way to gradually load the internal structures of the knee and provide the necessary muscle, ligament, bone and cartilage adaptation response required to return to running.
A very special thanks to Kat Gallucci for all of her hard work, and for her permission to share her ACL rehabilitation story.