There is a saying that ACL rehabilitation is easy until you start testing. Managing an ACL was easy in the 90s and noughties when I was a new grad. First, a binary diagnosis with a Lachman’s test, book surgery, and begin prehab ASAP post-injury. Then off for surgery at 2-4 weeks post-injury. Post-surgery, patients progressed through stages based on time. Rehab goals moved from pain control to muscle activation to balance, strength, power, and agility at set durations post-op. Then, return to sport at six months on the dot. But now, we understand that comprehensive rehabilitation is the key to better patient outcomes. It’s about progressing through stages and tailoring a rehab program to overcome power, strength, and other metrics deficiencies. This comprehensive approach takes considerable thought, skill, and equipment, but it’s what our patients deserve.
Nowadays, rehabbing a post-op ACL is – or should be if done correctly – much more complex, but it’s also more promising. This complexity is not a hurdle but a stepping stone towards better patient outcomes. Advancements in research and technology have made it more complicated for the therapist, but they are also the reason for improved patient outcomes. Thanks to a better understanding of key landmarks such as the Melbourne ACL Guide, and more technology to test, we progress according to test results rather than time. Extensive research has given us a greater understanding of ACL injury management, loading and rehabilitation. And, of course, the fast-growing area of ACL healing, selecting cases that are more likely to heal and optimising the ACL’s chance of healing using bracing protocols and loading.
It’s always complex once a patient has injured their ACL, regardless of their chosen pathway. If surgery is selected, we further understand the importance of quadricep strength in knee function and know that isolating the quadriceps through knee extensions produces the best outcomes. Progressing through stages of rehab by test results often sees us wait longer to return to running. Once we’ve progressed to late-stage rehabilitation and returned to the sport, we will have a wide array of measurement technology using tech-based equipment and isometric and isokinetic tests. Tailoring a rehab program to overcome these shortcomings identified in the testing takes considerable thought, skill and training equipment.
We also have benchmark returns to sport testing using pitch-ready, patient-reported outcome measure surveys and psychological readiness markers. Return to sport has moved out to a minimum of 9 months, with 12+ months standard.
It’s sobering that only about 20% of patients manage to complete their rehabilitation journey after ACL surgery. Most get bored, run out of finance or insurance and motivation, and are left with a weak leg for the rest of their lives. This statistic underscores the crucial role of motivation in the recovery. Equally important is choosing a physiotherapy provider with the expertise and facilities to conduct the necessary testing and rehabilitation loading for a return to full function. We now understand that returning to full function after an ACL injury requires much more equipment and expertise than a quick-witted physio with a wobble board and Reebok Step. Physio clinics are now looking more like high-tech gyms.
Life wasn’t meant to be easy!