The quality of rehab has a big impact on your recovery from ACL tear
What is the ACL?
The ACL or Anterior Cruciate ligament is an extremely important ligament in the knee that helps to stabilise the knee. It stops excessive forward translation of the tibia on the femur and prevents excessive rotation at the knee. The ACL also has proprioceptive fibres which help us with balance and the awareness of our body/knee in space.
In everyday life the ACL helps stabilise the knee in activities like walking, climbing stairs and crouching down. In sports the ACL is extremely important, especially with deceleration, pivoting/changing direction and jumping.
How common are ACL injuries?
This varies among sports. Sports with the highest rates are sports that involve lots of high-speed pivoting or change of direction. For example, field sports like GAA, soccer, rugby, hockey, and lacrosse have a high incidence while skiing also has a high incidence due to its high-speed nature and pivoting.
ACL tears are more likely to happen in women. Women have a 2.79 times higher incidence rate than males in soccer (Ferré-Aniorte et al.). This is down to anatomical, hormonal, and biomechanical differences between males and females.
How do ACL injuries occur?
70% of ACL injuries are non-contact injuries (Agel et al. 2016). These typically happen when decelerating, changing direction or landing from a jump during sporting tasks. Typically, the knee will fall inwards (knee valgus), while adduction happens at the hip and rotation (internal or external) happens at the knee.
30% of ACL are contact injuries (Agel et al. 2016). Contact injuries happen when a collision occurs that put the knee in a vulnerable position (as described above) unexpectedly.
If an ACL injury occurs there is normally a “pop” that the person feels, pain and immediate swelling with loss of function. Other concomitant injuries can occur with ACL tears such as, meniscus tears, PCL/MCL/LCL tears and bone injuries. Diagnosis of these injuries are made through MRI and you will see an Orthopaedic surgeon or Sports Medicine specialist to discuss your results have a clinical examination and discuss your treatment options.
What’s the treatment?
Depending on your activity levels, age and goals your consultant will help you to decide which option is best for you. Surgery and rehab or rehab alone. If you are a younger age, partake in change of direction sports and aim to continue playing at your highest levels, surgery will most likely be recommended.
Surgery is done through a ligament reconstruction where a graft is taken from either your patellar tendon, quads tendon or semitendinosus muscle. A donor graft may also be used in some circumstances. Post surgery rehabilitation is crucial to return to previous function. Book an appointment
Is all ACL rehab the same?
65% of people who get surgical reconstruction return to their previous activity levels, 55% return to sport, while 90% of elite footballers return to previous levels (Waldén et al. 2011; Ardern et al. 2014). This potentially highlights that the better quality the rehab and the more time for rehab the better the outcomes.
Return to play/sport after surgery should be based on passing return to play criteria rather than time-based measures. Your physiotherapist will use criteria like strength tests, hop/jump tests, and subjective questionnaires to guide progression through different stages of rehab rather than time. People who fail return to play criteria had a re-injury rate of 38% whereas those who pass this criteria have a 5% re-injury rate (Grindem et al. 2016). The average return to play time for non-elite athletes is 9-12 months. Returning after 9 months has been found to reduce the risk of re-injury (Grindem et al. 2016)
Surgery is not always the answer. For some people surgery is not necessary. For those who may be older, have no concomitant injuries and who do not want to return to change of direction sports rehab only may be an option. For those that maintain certain strength and have no giving way episodes rehab only may also be an option. 30-55% of people who completed non-operative management returned to sports in a study by Grindem et al. (2012). Saueressig et al. (2022) recommended a step-based approach to treatment, trialling rehab first and to get surgery if rehab fails. This option may not be time efficient and for those in a hurry surgery may be the best option.
Is surgery always necessary?
Rehabilitation whether that be post-surgery or with conservative management will have a different focus depending on the stage you are at. The first goal typically from day 0 to 1 month is to reduce and eliminate swelling while regaining full range of movement in your knee. Once this is achieved the focus to regain certain strength targets and symmetrical strength is your leg muscles, this normally occurs between 3-6 months. The next focus will be to increase plyometric capability by training landing and jumping typically from 3 months to discharge. Finally return to running and change of direction will be the focus with a gradual reintroduction into a team setting following.
These stages are not independent to each other, they will overlap. Your physiotherapist will progress your rehab exercises as you pass through each stage. They will have certain markers that you have to pass on different tests to progress through each stage. Everybody is different, finding different areas of rehab harder. The key is to stay consistent, listen to your physio and focus on the next goal ahead and not jump too far ahead of yourself. Book an appointment
Common Questions
When can I run again? – This depends on the phase of rehab you are in. Typically return to running is achieved when the athlete has symmetrical range of movement, no swelling and have less then 10% difference in strength tests for quads, hamstrings, and calf muscles.
Can the ACL tear again? – Yes, and like any other injury, you are more likely to tear your ACL if you had a previous ACL tear. However, with consistent rehab and passing return to play tests the risk of re-injury is low at 5%.
Can I return to the level I was pre-injury? – Yes of course, and you can even perform better on your return. Treat the rehab journey as an opportunity to get stronger than you were before, faster than you were before and more resilient than you were before. This is done by having the time in the gym to address any weaknesses or asymmetries that you may have while working on your running technique and jumping capabilities.
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Oisin Kelly, BSc, MSc (Sports Medicine), MISCP CORU Chartered Physiotherapist
Agel J, Rockwood T & Klossner D. (2016). Collegiate ACL Injury Rates Across 15 Sports: National Collegiate Athletic Association Injury Surveillance System Data Update (2004-2005 Through 2012-2013). Clinical Journal of Sport Medicine 26, 518-523.
Ardern CL, Taylor NF, Feller JA & Webster KE. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 48, 1543-1552.
Ferré-Aniorte A, Bolibar I, Cugat R & Alentorn-Geli E. Anterior cruciate ligament injury incidence in male and female soccer players: A longitudinal study over six consecutive seasons. Knee Surgery, Sports Traumatology, Arthroscopy n/a.
Grindem H, Eitzen I, Moksnes H, Snyder-Mackler L & Risberg MA. (2012). A pair-matched comparison of return to pivoting sports at 1 year in anterior cruciate ligament-injured patients after a nonoperative versus an operative treatment course. Am J Sports Med 40, 2509-2516.
Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L & Risberg MA. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports Med 50, 804-808.
Saueressig T, Braun T, Steglich N, Diemer F, Zebisch J, Herbst M, Zinser W, Owen PJ & Belavy DL. (2022). Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis. Br J Sports Med 56, 1241-1251.
Waldén M, Hägglund M, Magnusson H & Ekstrand J. (2011). Anterior cruciate ligament injury in elite football: a prospective three-cohort study. Knee Surg Sports Traumatol Arthrosc 19, 11-19.