By Wesley Wang, DPT
In my opinion, not every physical therapist is qualified to treat ACLs from start to finish. While this statement may ruffle some feathers, let me present you with an analogy that may help put things in perspective. If your car starts having issues, do you take it to just any average mechanic or try to find the best one for your specific type of car? If you’re looking to improve your skills in a specific sport, do you hire an average coach or try to find a specific one for your specific sport? While these examples aren’t perfect, recovering from ACL surgery is a lengthy process and finding the right therapist can significantly improve outcomes.
There are many components that need to be addressed in physical therapy to ensure full recovery. Research provides detailed guidelines on specific factors including range of motion, strength, movement assessments and return-to-sport testing which should all consistently be addressed to ensure athletes are safe to go back to sports. These seemingly minor details can significantly decrease second ACL injuries which are reported to be approximately 1 in every 4 to 5 patients. (1,3) Coming back to the mechanic example, would you want a mechanic who wasn’t detail oriented examining your car? Would you want a coach who didn’t use the latest methods to optimize your training sessions?
The entire ACL recovery process takes approximately 9-12 months and sometimes even longer. Research tells us that nine months is the minimum recovery time after surgery and returning too early increases the risk of a second ACL injury. (2) There is simply too much to address in ACL rehabilitation and returning to sports too early is just not worth the risk.
There are two major components of ACL rehabilitation, strength and neuromuscular control. Limb asymmetries which includes range of motion and strength are pivotal for optimal recovery. One of the primary foundations of ACL rehabilitation is achieving full range of motion. For example, if the knee can’t fully extend (straighten), it makes it extremely difficult for the quadriceps to regain full strength. Obtaining greater than 90% quadricep strength and a hamstring-to-quad ratio of at least 85% (compared to the non-operated knee) have been shown to significantly decrease second ACL injuries. (1,2)
Dynamic neuromuscular control involves how the athlete is able to control their body when performing tasks such as balancing, jumping and landing. When performing these tasks, the athlete should be able to demonstrate proper control of their trunk, hips, and knee. For example, when landing on the surgical knee (once it’s safe to do so of course), there should be minimal upper body movement such as the trunk swaying from side to side or the hips twisting and minimal knee movement particularly into valgus (inward). (1,3) Return-to-sport tests identify deficiencies and one study found that successfully completing return-to-sport criteria reduces re-injuries by 32.5%. (2)
Additionally, physical therapists should have knowledge of various exercises to consistently challenge patients in their recovery process which includes both strength and dynamic control. This is a big issue in rehab as I’ve heard from many patients that they weren’t challenged in their previous physical therapy facilities and instead repetitively performed simple exercises. Athletes should be challenged in every physical therapy session or we are doing our athletes a disservice.
Finding the right physical therapist for ACL recovery is absolutely necessary to safely return to sports. The physical therapist should utilize up-to-date research and be able to properly progress and challenge patients to significantly improve outcomes following ACL surgery.
- Hewitt T, Di Stasi S, Myer G. Current Concepts for Injury Prevention in Athletes After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2013 Jan: 41(1): 216-224
- Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg M. Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Deleware-Oslo ACL cohort study. British Journal of Sports Medicine. 2016 May.
- Wiggins AJ,Grandhi RK, Schneider DK, Stanfiel D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul:44(7):1861-76.