Life After ACL Reconstruction: Avoiding the Dreaded Re-Injury
Post by Laura Gold PT, DPT
ACL injuries are a common season-ending injury among athletes. Given the severity of the injury, many athletes opt for surgical repair of the damaged ligament in order to regain stability at the knee. While a number of athletes who undergo ACL reconstruction return to their sport, less than half of individuals make a full return to their activities following rehabilitation. According to one study looking specifically at high school and college athletes returning to sport following ACL reconstruction, only 50% reported they were able to perform at their pre-injury level. What’s more, somewhere between 6 and 30% of the post-reconstruction population experiences a second ACL injury.
As a therapist involved in the rehabilitation of those with the misfortune of tearing an ACL, my goal is to make sure that not only is the athlete able to get back into the game, but that we are addressing any neuromuscular deficits or movement inefficiencies that could put the patient at risk for re-injury.
A study published in the November 2013 issue of the Journal of Orthopedic and Sports Physical Therapy highlights the primary neuromuscular deficits that plague individuals post ACL repair and often persist despite formal rehabilitation. These deficits include poor strength symmetry in the quads and the hamstrings (compared to uninjured knee); high risk biomechanics, such as poor ability to control the knee motion with weight-bearing, jumping, or cutting; and deficits in high-level sports related function. Let’s break down these deficits a little further.
Poor Strength Symmetry in the Quads and Hamstrings
Of the three neuromuscular deficits above, this one is probably the most simple and straightforward to address and often stares us right in the face in the form of obvious muscle atrophy. Quads and hamstrings are often the focus of ACL rehab as it is currently practiced. The problem here occurs when return to sport is attempted before an adequate level of symmetry is achieved.
High Risk Biomechanics
The JOSPT article mentioned above summarizes in detail the research on biomechanical inefficiencies observed before the injury, during rehab, and following rehab. To keep it simple, these inefficiencies are related to two areas: control of knee motion in 3 dimensions (forward/back, side-to-side, and rotation) and trunk control (synonymous with core stability). The article also provides evidence-based exercise progressions designed to address these inefficiencies. The common theme among almost every exercise progression in the article is strengthening and functional retraining of the gluteal muscles: gluteus maximus, gluteus medius, and gluteus minimus. In the area of PT where quad and hamstring strength is emphasized, functional knee control mediated from these hip stabilizers is often overlooked or not given the attention it deserves.
Deficits in High-Level Sports Related Function
The final area of neuromuscular deficits relates to translating the system, mobility, and neuromuscular coordination gains into high level function. Whether it be limitations on rehab visits with insurance coverage; difficulty coordinating the athlete’s schedule to continue regular rehab or athletes and coaches that are eager for return to sport; this last and perhaps most crucial phase of rehab often gets cut short or skipped altogether. As physical therapists, we can rehab someone to have excellent strength, mobility, and stability following an injury, but if we never integrate these gains into function (sport specific movements and environment) then the athlete has an increased risk of re-injury.
Are you recovering from an ACL injury? Have you returned to your sport post-ACL surgery but still feel like you aren’t full speed? Interested in taking the extra steps to prevent an ACL injury in the first place? Come see us as Movement Sports Physical Therapy and we can help with prevention, rehabilitation, or with closing that final gap to get you back to your sport!