At Melbourne CBD Physiotherapy and Sports Medicinetherapy and Sports Medicine
we know the road to recovery following ACL injury is certainly a long, and one that requires persistence, patience and a healthcare team experienced with ACL rehab. This post shares the common questions patients typically have regarding ACL rehabilitation
and incorporate the latest evidence-based practice.
"Is there a difference between grafts?"
In Australia, hamstring tendon (HT) graft is by far the most common choice for ACL reconstruction. While individual factors such as general health, previous knee injuries and anatomy of your knee will contribute to the graft choice decision, you should be aware that other types of graft exist, such as the quadriceps tendon (QT) and bone-patella tendon-bone (BPTB) which offer unique strengths and limitations. Let’s take a look at the main differences to consider.
Hamstring tendon autograft
(harvested from the affected knee)(1-5)
Bone-Patella Tendon-Bone autograft (1-5)
|Surgeons are well trained in Australia to perform this technique
Less donor site pain compared to BPTB
Similar level of overall knee function compared to BPTB
||Associated with lower end range of motion knee flexion strength
Increased risk of graft failure compared to BPTB
Lower overall knee function compared to QT graft
Quadriceps tendon autograft (1-5)
|Better overall knee strength compared to HTLower risk of graft failure compared to HT
Similar overall knee function compared to HT and QT
|| Increased knee pain at surgical site compared to HT and QT
Increased risk of knee pain during kneeling or deep squatting positions compared HT
Not all surgeons are trained for this technique
"How long does rehabilitation take and when can I return to sport?"
|Less donor site pain compared to BPTB (similar to HT pain)
Overall better patient reported knee function than HT
Lower risk of knee pain with squatting, kneeling and/or deep flexion related activities
Lower postoperative knee laxity compared to HT
|| No better than HT or BPTB grafts for return to sport or graft failure
Risk of reinjury similar to HT and BPTB
A common myth is the notion that all ACL rehab
is time based, meaning at around 9-12 months you will return to sport. Moreover, there is also no defining test/s that will definitively tell you when return to sport is safe. In fact, rehabilitation and return to sport decisions are normally criteria based, meaning that in order to progress your exercises and test whether you are ready for return to sport, a range of different strength measures, hop tests and patient reported symptoms need to be achieved. Recent evidence shows that most people are cleared for return to sport when > 90-95% symmetry on various hop tests and strength measures are achieved, in combination with minimal psychological and/or knee related symptoms(6)
. This level of physical function reduces risk of graft rupture by approximately 60%, however it increases risk of contralateral (opposite limb) rupture by 235%(6)
- so there’s a lot more research to be done!
"What’s the risk of reinjury once you’ve returned to sport?"
The risk of reinjury is a serious topic to consider as up to 40% of patients have been reported to suffer a subsequent tear!(7)
Therefore, it’s imperative that factors associated with a high risk of reinjury are addressed at the time of return to sport and managed throughout competition. Interestingly, females < 19 years old are at the highest risk (8)
, something to keep in mind for female patients playing sports such as AFLW, soccer, netball and basketball. Moreover, these additional factors can increase risk by up to 5 times (8, 9)
The message is clear regarding ACL rehabilitation: be patient, be consistent and be goal oriented!
Dr. Tim Sayer
- Triple leg hop distance < 1.90 x height
- Limb symmetry < 98.5%
- Quads symmetry below 90%
- Tampa Scale of Kinesophobia (i.e., fear of certain movement) > 17 at return to sport
Melbourne CBD Physiotherapy and Sports Medicinetherapy and Sports Medicine
- Huber R, Viecelli C, Bizzini M, Friesenbichler B, Dohm-Acker M, Rosenheck T, et al. Knee extensor and flexor strength before and after anterior cruciate ligament reconstruction in a large sample of patients: influence of graft type. The Physician and sportsmedicine. 2019;47(1):85-90.
- Laboute E, James-Belin E, Puig PL, Trouve P, Verhaeghe E. Graft failure is more frequent after hamstring than patellar tendon autograft. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2018;26(12):3537-46.
- Mouarbes D, Menetrey J, Marot V, Courtot L, Berard E, Cavaignac E. Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Outcomes for Quadriceps Tendon Autograft Versus Bone-Patellar Tendon-Bone and Hamstring-Tendon Autografts. The American journal of sports medicine. 2019:363546518825340.
- Wipfler B, Donner S, Zechmann CM, Springer J, Siebold R, Paessler HH. Anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon: a prospective comparative study with 9-year follow-up. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2011;27(5):653-65.
- Belk JW, Kraeutler MJ, Marshall HA, Goodrich JA, McCarty EC. Quadriceps Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review of Comparative Studies With Minimum 2-Year Follow-Up. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2018;34(5):1699-707.
- Webster KE, Hewett TE. What is the Evidence for and Validity of Return-to-Sport Testing after Anterior Cruciate Ligament Reconstruction Surgery? A Systematic Review and Meta-Analysis. Sports medicine (Auckland, NZ). 2019.
- Webster KE, Feller JA. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 2016;44(11):2827-32.
- Paterno MV, Huang B, Thomas S, Hewett TE, Schmitt LC. Clinical Factors That Predict a Second ACL Injury After ACL Reconstruction and Return to Sport: Preliminary Development of a Clinical Decision Algorithm. Orthopaedic journal of sports medicine. 2017;5(12):2325967117745279.
- Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study. Sports health. 2018;10(3):228-33.