Anterior Cruciate Ligament (ACL) Function
Unfortunately, anterior cruciate ligament (ACL) injuries are common in sports people and negatively impact on a person’s physical capacity. The ACL functions to give your knee rotational stability which is particularly useful when playing pivoting sports. Without an ACL, the risk of partially dislocating your knee when you pivot is higher. With each dislocation episode, other structures inside the knee (such as your meniscus or cartilage) may become injured too. The downstream consequence of an unstable ACL-deficient knee is early osteoarthritis (a painful stiff knee with no cure).
The majority of people who injure their ACL can expect a degree of osteoarthritis (OA) 10 to 15 years after their injury. To minimize the risk of developing OA you need to restore stability to your knee – this means being able to perform activity without your knee ‘giving way’. Some people can achieve a stable knee without surgery. Research suggests that patients with stable ACL-deficient knees (no reconstruction surgery) can return to the same level of activity. They also experience the same quality of life as people who have undergone an ACL reconstruction. However, many people require an ACL reconstruction operation to have a stable knee.
ACL Injury Recovery Time and Return to Sport
The commonest measure of successful treatment after an ACL injury is return to sport. When people injure their ACL playing sport, most are justifiably anxious at the thought that they may have to quit pivoting sports as a result of their injury. Trying to return people to pivoting sports with an ACL reconstruction has therefore been the noble aim for many surgeons. But how successfully is this aim achieved?
The answer to this depends on your level of sport, your age at the time of injury and whether you are male or female! 85% of elite / professional athletes return to sport of some type. 79% return to the same level of sport as pre-injury. Overall that is a fantastic outcome given ACL injury used to be an injury which forced retirement of elite athletes. However, be mindful that results in elite athletes cannot be applied to the general population. Results tend to be better in elite athletes for many reasons, including:
- Daily personalized rehab with skilled Sports Physiotherapists with appropriate goal-setting and close monitoring of objective measures such as strength and landing technique
- Access to top ACL surgeons
- Increased motivation as their livelihood is on the line
- Increased emphasis on identifying and treating psychological factors such as fear of re-injury
Unfortunately the numbers don’t make as good reading for non-elite athletes. Although 80% still return to some type of sport, only 60% ever return to their pre-injury level of sport and only 42% return to competitive sport. These return to sport rates are even worse in older patients and females. Don’t misunderstand me though – these rates are still good for a devastating serious knee injury, but having an ACL reconstruction does not guarantee a return to your pre-injury sport by any means.
Can You Improve Your Chances of Return To Sport After an ACL Reconstruction?
YES!!!! YES!!!! and YES!!!! Several key factors can affect your chances of return to sport that are modifiable (you have the power to change);
1. Pre-Operative Assessment and Education
- Seeing a Specialist Sports Physician or an Orthopaedic ACL Surgeon allows for correct assessment of injuries that can occur frequently with an ACL rupture which may need to be treated prior to surgery and may affect the type of surgery you need and/or alter your specific rehab needs.
- Assessment of your mindset allows implementation of specific treatment strategies to overcome barriers to your recovery
2. Pre-Operative Rehabilitation with Sports Physiotherapists
- Physiotherapists have widely varied skill sets. Sports Physiotherapists have an interest and training in managing sports injuries, such as ACL injury, and should be aware of key research in the field of ACL recovery. This is certainly the case with the physiotherapists at Newcastle Sports Medicine.
- Several studies have demonstrated that a specific pre-operative rehabilitation program aimed at progressive muscle strengthening as well as high end balance work not only improves knee pain and function prior to surgery but also improves long term outcomes after surgery.
- Following this evidence-based rehab program improves return to sport rates by a further 10% (60% to 70%).
- Weak quadriceps (thigh) muscles pre-op results in weak quadriceps persisting up to 2 years at least post-surgery!
- Patient’s have better outcomes with stronger quadriceps (<20% difference to the uninjured leg). This can be measured formally with isokinetic machines (usually only possible in research environments) or with handheld dynamometry (ask your treating physio for this if it hasn’t been performed).
3. Timing of Your Surgery
- In an effort to return to sport ASAP, people often opt to have their surgery as soon as possible. This can produce adverse responses though. Post-operative stiffness and pain is minimised if a full range of motion and no swelling is achieved pre-operatively.
4. Choose Your Surgeon Wisely: As with anything in life, Experience Counts!
- Multiple reconstruction options are available, but the key factor is to have your surgery performed by a surgeon who performs many ACL reconstructions a year. This is something your Sports Physician can help you determine.
5. Effective Post-Operative Rehabilitation
Many surgeons and physiotherapists use points in time to determine when you are ready to return to sport. We know that changing this approach to goal-oriented rehab progression (hitting functional targets and measures) is more successful and results in better overall function. Clearly it doesn’t matter if 9 months have passed, if your quads are too weak to land from a jump shot or change direction at high speed, your risk of re-injury is much higher. Be very wary of being advised that you are ready to return to sport at 6 months without having passed a battery of physical tests. We all want to be told we are ready to go back to sport, but your chance of re-injury is much higher if you haven’t fulfilled certain criteria.
6. Demonstrate Psychological Readiness to Return to Sport
- Humans are intuitive creatures and sometimes we just don’t feel right about returning to play. Sometimes these fears are a reflection of not being physically ready but frequently these fears exceed what is rationale and impair our ability to return to exercise. In these cases, it is important to seek psychological assistance and to not pressure people to return to activity before they feel ready. Your Sports Physician or Sports Physiotherapist can perform tests to identify at risk individuals and help put you in touch with the right people to move forward with confidence.
What Is The ACL Re-Injury Rate?
Re-injury is not rare, particularly in females and young athletes. Studies looking at re-injury rates have several flaws but still give a guide to expected outcomes. The overall likelihood of another ACL injury (either the graft or the previously uninjured knee) within 24 months of ACL surgery on return to sport is 6 times higher than the risk of uninjured athletes. Overall 30% of athletes had a re-injury within 2 years of returning to pivoting sports. Interestingly, 66% of the re-injuries occurred in the uninjured ACL and 33% in the reconstructed ACL.
Please contact us if you need assistance with your ACL injury. If you think you have injured your cruciate ligament recently, you will be able to access an urgent appointment or will be seen in the acute sports injury clinic on Monday afternoons.
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