Ouch! You just had your ACL surgery and probably feel like you will never play your sport again….I get a lot of questions from many different level athletes regarding “How I should rehabilitate my ACL injury” and “why does my knee still feel unstable after a year of rehabilitation”. First off, I never tell my athletes they will never play again. I tell them you will play again, just takes time to recover from this injury, and that time you use to recover needs to be well spent!
Less than a half of athletes return to their sport after their first year following an ACL repair, and about 1 in 5 athletes will require a second surgery. As a health care provider, one of the biggest things to consider in your athlete is their neuromuscular control during dynamic movements. Any deficits in this system will result in increasing the chances of re-injury if no attention is paid to during rehabilitation.
After an ACL repair it is common to have muscle weakness, impaired movement, abnormal neuromuscular control and difficulty returning to your sport. These can lead to asymmetrical imbalances between both knees and hips and abnormal pelvic control. Some things to watch out for that affect neuromuscular control are: muscle weakness (or inhibition as I rather call it), joint effusion, abnormal ROM and impaired function, which can last up to several months following ACL repair. It is important to communicate that this process is going to take a little longer than normal to heal the ACL and get it back to functional working capacity for their sport.
When assessing neuromuscular control with your ACL repair patients, health care providers should be sensitive at picking up any: increases in external knee abduction, excessive out-of-plane knee loads, any frontal displacement of the trunk, decreased core proprioception, lower extremity biomechanical differences and flexor activation, between sides. Some test I like to use with my ACL patients to help assess for any asymmetries would be the Non-Weighted Front Squat, Prone Isolated Gluteal extension, Single Limb Hop Test, Tuck Jump, Drop Vertical Jump test and assessment of Deep Breathing Techniques. It is important to look for asymmetrical movement patterns during these tests, and even be sure to look at the opposite side (knee and hip)! In fact, I would argue that many health care providers don’t spend time assessing the opposite side (probably because we are driving toward a pain focused program of care and because we only spend about 15-20 minutes with a patient). Research has suggested that compensatory strategies of the uninvolved hip (transverse plane) are a primary predictor of risk factor for developing a secondary ACL injury. Other researchers argue to look at frontal knee plane and sagittal knee plan motions and postural stability as other risk factors to secondary injury. So, lets be smart health care providers when taking on a patient with ACL injury and preparing them to return to sport. I forgot to mention, we should also be looking for strength ratio symmetry between the quads and hamstrings (tests like the single hop test will help with this).
Ultimately it is the discretion of the health care provider to progress the athletes into the proper stages of rehabilitation while assessing neuromuscular deficits. There should always be good communication with the athlete and proper clinical judgment used when creating a proper progressive plan of management. I mean you shouldn’t get your ACL repair patient to do single leg hop after 1 week of surgery, duh! The main thing is to focus on restoration of symmetrical function and use those aforementioned tests to help determine the progress of any neuromuscular deficits as this is a big factor (I argue for it) in re-injury.
Now go out there and rehab properly, soccer season is approaching, wait isn’t it always soccer season?
Dr. Nourus Yacoub, DC