Return to sports after knee surgery, is it possible?
Whether you are a top athlete or an amateur, it will happen to you do one day or later: you will have a sports injury.
One of the most common dramatic sports injuries is a torn anterior cruciate ligament, abbreviated to ACL.
When you tear your anterior cruciate ligament or ACL your knee swells with blood. When the knee swells, that triggers a cascade of events which causes you to lose quadriceps strength. In addition you will notice that your thigh looks a lot smaller than the other one. That is due to atrophy of the quadriceps which occurs after an ACL injury.
In addition to the loss of quadriceps strength and atrophy which accompanies an ACL tear you will also notice loss of motion and in most cases a fair amount of pain.
Many athletes choose to have ACL surgery to improve their chance of returning to the same level of performance as they had before.
The sad reality is that many athletes can not return to sports after ACL surgery. The reasons for this vary. As such, there is a lot of research taking place to improve your chance for a successful return to sports after an ACL reconstruction.
But first the question whether ACL surgery should be done.
Who should consider ACL surgery?
ACL tears are are occurring at an alarming rate. With lifelong implications, an ACL tear can be a devastating injury, especially in a teenager. While 65-80% of athletes can expect to return to sports, that means that more than 20% will not. More worrisome is an ACL re-injury rate of 15-20% despite a well-performed reconstruction and well-executed rehabilitation phase.
There is a common misconception in the patient community that ACL tears are a straightforward problem with a simple solution. Nothing could be further from the truth. Who requires an ACL reconstruction, how should the reconstruction be performed, which graft should be used to repair the ACL and when can an athlete return to sports are very important considerations that surgeons and patients wrestle with on a daily basis.
Most experts agree that
1 not all patients need to consider an ACL reconstruction… but most do.
2 if you have also torn a meniscus or if you have torn more than one ligament then surgery to reconstruct your ACL is likely to be your best option
3 people who choose not to have an ACL reconstruction are at high risk for secondary injuries such as a meniscus tear or an injury to the cartilage or cushioning on the ends of our bones. Both of these injuries dramatically increase your risk for developing arthritis in the knee.
Can ACL tears be repaired?
Tears of the anterior cruciate ligament or ACL have become commonplace on the ball fields across the world. ACL injuries are usually treated with a reconstruction or a replacement of the torn tendon. Should we be repairing your ACL tear instead of replacing it with a graft?
Your normal ACL has special nerves in it. These nerves provide proprioceptive feedback. That means that the nerves in the ACL help you know the position of your knee in space without looking at your knee… your brain can sense where it is based on the proprioceptive nerve fibers. Anyway, it turns out that proprioception is becoming a strong predictor of joint stability. If we improve your proprioception following ankle sprains and other injuries your perception of joint stability improves. This is also felt to be the reason why compression knee sleeves work to improve your sense of knee stability.
When the ACL tears those special nerves are torn too. Following a routine ACL reconstruction the nerves do not regenerate. Therefore your new ACL does not contribute any proprioceptive feedback to your brain. This might explain why many knees still feel unstable and it may explain, in part, the risk of developing osteoarthritis.
In general, repairing torn tendons or ligaments is preferred over reconstructing them.
Return to Sports After ACL Surgery
The statistics can be alarming. You might have a 45% risk of tearing your new ACL if you have not rehabilitated your knee properly. You can drive that risk down to 18-20% with the proper training.
The first goal of your physical therapy after ACL surgery early on is to get back your motion and strength. The later stages of the recovery process involves improving your balance, agility, jumping and landing skills. Doing so will decrease the risk of re-injuring your knee and re-tearing your ACL. Your recovery from an ACL reconstruction involves not only the physical aspects of your recovery, but perhaps equally as important, the emotional and psychological components.
The research regarding the immediate management of an athlete after ACL surgery continues to evolve. It turns out that immediate PT might weaken your new ACL graft. Some surgeons are starting physical therapy a week or two after surgery because of this research. Once PT has started, the research today shows that many people will tolerate an accelerated ACL surgery physical therapy program and be able to return to sports as early as 8 months. There are many experts who feel that might be too early. Thus there is a lot of confusion on the proper way to return to sports after ACL surgery.
Bottom line: do not rush your return to sports. Get that leg and your mechanics and stability as close to normal as possible. It will be time well spent.
Prehabilitation Before ACL SurgeryOrthopedic surgeons for years have been placing patients into physical therapy to improve their motion, minimize their pain and start to improve their quadriceps strength before ACL surgery. Until recently there wasn't proof that this made much of a difference in your final result after your ACL reconstruction. In addition, it was not known if specific neuromuscular training before surgery would also be of benefit.
That is, until a comparison was made between two groups of patients that either received prehabilitation or didn't .
Not surprisingly, patients who underwent physical therapy before surgery achieved certain milestones more rapidly after surgery.
The benefit is most likely related to the addition of neuromuscular training to the prehab protocol.
For the athlete, the research showed that there was better function and a higher return to sports rate when the athlete had therapy before ACL surgery.
The return to sports rate after ACL surgery is currently lower than we like it to be.
With the knowledge that physical therapy or prehab before ACL surgery improves functional outcomes and facilitates a higher return to sports rate, it is strongly recommended to consider prehab or physical therapy before surgery as science strongly suggests this is a good idea.
For all who suffer an ACL tear, surgery is only a small part of the recovery and return to sports process. A successful return to sports after ACL surgery depends on many factors.
The psychological aspects of recovery after an ACL injury are neglected for many. Even the toughest patients require a team that will look after their physical as well as their psychological recovery to enable them to return to play after an ACL injury.
Sometimes the athlete’s physical issues are addressed, but they were not prepared emotionally and psychologically for a return to sports, and in the end you have an athlete ill-suited for a return to their chosen sport.
From American research data on young high school and collage athletes, it shows that fewer athletes return to sports than predicted and those that do return, don't always manage to play sports at the same level as before.
The reasons quoted for this are that the athletes had to miss more training sessions upon return than before their surgery and also were more likely to sustain a new injury.
Outside of the anatomical and biomechanical factors, here are other factors: young athletes who suffer an ACL injury tend to experience more depression, have a fear of re-injury, have decreased sport satisfaction, and lower test grades in school as a result of their injury.
A major influence on a successful return is the role of the rehab provider in psychologically preparing the athlete.
Making sure athletes know they have an active role in the process and it takes hard work, but at the end of the day, they can and will control their destiny.
The rehab provider must also be able to build the patient’s confidence during the course of rehabilitation.
Building the confidence in the limb as soon as possible so that an athlete can see putting weight on the leg will not result in re-injury.
By making an athlete work hard and pushing them physically, will build mental toughness and confidence.
The athlete should also not have overly optimistic expections nor be confronted with conflicting opinions by the surgeon and rehab provider.
Return to sports guidelines
prehabilitation phase: Prior to surgery, work with your healthcare practitioner to maximize knee extension range of motion and strengthen your quads.
week 0-3: early post-operative phase
For the first few weeks after surgery, use cold and compression to reduce knee swelling. At the same time, work to regain your knee extension and quad strength. After consulting with your surgeon, you may start manual therapy, pool walking, and low resistance stationary cycling.
week 3-7: controlled walking phase
You may now begin to stretch and strengthen your hips, hamstrings, quadriceps, and calf muscles with load bearing light strength training. Start to include balance work and improve your cardiovascular fitness on the bicycle.
week 7-12: moderate protection phase
You should now be doing full body strength training like step ups, mini squats, and leg press in a slow and controlled manner. Increase your speed and directional changes in the pool and consider a stair-master or elliptical machine for cardiovascular variety.
week 12-16 : light activity phase
Continue full body strength training while adding in light plyometric, agility, and running drills to begin to lightly mimic sport.
month 3-9 : return to sport preparation phase
Progress to advanced balance, agility, strength, power, and cardiovascular exercises with the goal of movement quality and symmetry.
Sport specific training involving movement redirection and jumping in a controlled manner. Return to individual practice can occur in the second half of this phase if Return to Sport Criteria are met.
Return to Sport Criteria
Return to to sport should be a time and function based decision and should not occur before 9-months post surgery.
The criteria which much be met before returning to sports are:
1 You should have complete and pain free hip, knee, and ankle range of motion.
2 Your quality of gait, jumping, running, and cutting should be demonstrated with no compensation or apprehension.
3 The laxity of your knee should be tested by the orthopaedic surgeon.
4 your strength should be assessed at various knee angles using objective measures like isokinetic testing
5 balance training should have advanced to include sport specific multi-directional and multi-force perturbations that mimic the unpredictable nature of your sport.
Gradual return to play should involve a number of weeks in non-contact practice, followed by a number of weeks of gradual playing time within contact practice, followed by gradual playing time within games. The goal of the return to sport process is to gradually load your knee within your sport, while at the same time allowing for adequate recovery and monitoring of progress. It is advised to err on the side of caution and use longer timeframes for return to game play!