I recently attended a Seminar on Return to Play after Anterior Cruciate Ligament (ACL) Reconstruction in athletes. Speakers on the day were Mr. Declan Bowler, Consultant Orthopaedic Surgeon at the Mater Private Hospital in Cork, and Dr. Phil Glasgow, Head of Sport’s Medicine at the Sports Institute of Northern Ireland. The aim of the Seminar was to give physiotherapists a greater understanding of when an athlete is fit to return to his or her chosen sport after injury.
SOME FACTS ABOUT AN ACL INJURY:
• 20% of people who tear their ACL will never return to sport again
• The injury is far more common in females than males, with a ratio of approximately
• Time from injury to return to sport varies greatly, with some elite athletes returning after 5 months, others taking over a year
There are many factors that can predispose a person to an ACL injury. These include inadequate hip strength, poor trunk stability, altered foot posture, imbalance between quads and hamstring strength and poor landing biomechanics. Other factors such as playing surface and type of boots/studs worn may also have an impact but evidence varies on this.
Once a person sustains an injury, the primary aims are to reduce swelling, restore normal range of movement (ROM) and improve strength around the knee. This is essential prior to surgery and also helps recovery post-operatively.
While traditionally rehabilitation programmes have been built around time-based goals, evidence now suggests that time should not be the most important factor in deciding if a person is ready to move onto the next stage of their rehab, or indeed return to play. Instead, functional outcomes should be the main indicator of a person’s progress, and unless they can complete a series of tasks well, with good movement control, then they should not progress onto the next stage. The time taken to reach these functional goals can vary greatly between people, and often depends on their pre-operative ability, along with the time they have to dedicate towards their recovery. Dr. Phil Glasgow, who works with elite athletes, believes that if a person cannot dedicate at least 4 hours a day to their recovery, then the time to return to play will naturally be lengthened. 4 hours a day may be feasible for a professional athlete but is not a realistic goal for the majority of amateur athletes. It is therefore also not helpful to compare your progress to an elite athlete, or rush your rehab to match theirs.
As well as rehabilitating the knee and surrounding structures, another crucial part of rehabilitation is addressing the underlying reason for the injury in the first place. This may mean working on trunk and core stability, hip strengthening, balance and control of your lower limb, among other issues.
ACL injuries continue to be feared amongst amateur and professional athletes alike, and although the road to recovery can seem daunting, it is crucial to take the time to work through your programme and focus on performing exercises well, and with good form, rather than rushing through or performing large repetitions with poor control. Time is no longer an accurate guideline for return to play, functional goals are far more important.