Anterior cruciate ligament (ACL) injuries are becoming more and more common, particularly in our younger athletes. Alas, even after all of the research and surgeries performed, we aren’t significantly changing the number of re-injuries that are happening. ACL rehabilitation and optimising the return to sport process through a criteria-based progression and program is currently the best evidenced based practice. At PRP Physio I have developed an ACL rehabilitation program that takes you from initial injury management all the way through to return to sport and is inclusive of an ongoing injury prevention program. I genuinely believe that physiotherapy is the best sports medicine to maximise an athlete’s recovery and their performance on returning to sport.
ACL injuries occur often in many different Australian sports like soccer, AFL, netball, and rugby league and rugby union. The common factor between all of these sports is that they are multi-directional 360-degree games. Preparing an athlete to return to their prior level of performance and reducing their risk of another knee injury takes exposure to specific sports physical therapy and patterns. I believe in an early loading program that develops early strength improvements and allows for exposure to basic sport-specific movements to develop confidence in the knee.
The program that I have developed is specifically designed for an athlete who desires to not only return to sport but exceed the level of performance they were previously at. My goal is to make each athlete more robust and complete than they were prior to their injury.
A torn ACL is an injury to the anterior cruciate ligament (ACL), which is one of the four main ligaments that stabilise the knee joint. The ACL connects the thigh bone (femur) to the shin bone (tibia) and prevents the shin bone from sliding forward too much. The ACL also helps control the rotation of the knee.
ACL injuries vary in severity from mild sprains (Grade 1) to partial tears (Grade 2) to complete tears (Grade 3). A partial ACL tear refers to damage to only a portion of the ligament without completely severing it. This typically occurs when the ligament is stretched and becomes loose but still maintains some continuity. A complete ACL tear involves a total rupture of the ligament. This means that the ACL has been severed into two separate ends, resulting in a significant loss of knee stability.
An ACL tear can happen when the knee is twisted or bent in an unnatural way, such as during a sudden change of direction, landing from a jump, or a direct blow to the knee. When the ACL is torn, it can cause a popping sound or sensation in the knee, followed by pain, swelling, and instability.
The ACL is most commonly injured during knee flexion, which is when the knee is bent. This reduces the space between the thigh bone and the shin bone, which increases the tension on the ACL. When the knee is straightened (knee extension), the space between the bones increases and the tension on the ACL decreases.
Suffering an anterior cruciate ligament injury is one of the most frustrating injuries, you were playing your sport perfectly fine and then you went to change direction and your knee buckled underneath you. It’s one of the most common stories we hear but it isn’t the only story. The first discussion point in our assessment will be a description of how the injury occurred. This provides me with a great deal of insight into potential contributing factors to the injury as well as assisting in the diagnostic process. Sensations that you felt at the time such as pop, snap, crack, or any other sensation you may have felt is an important detail to pass on.
ACL injuries can be relatively distinct from other knee injuries in how they respond within the first few hours post-injury. An ACL injury is going to swell up and it will swell up fast, so swelling is always a question I will ask along with any other symptoms or sensations you felt within the following 24 to 48 hours after the injury. One of the common sensations people can describe to me is the sensation of looseness, knee instability, or like the knee wanting to give way on them during day-to-day life. Other potential sensations you may feel could include a locking, catching, or clicking sensation deep within the knee joint, these sensations could potentially indicate the presence of a meniscal tear.
Your previous injury and medical history will be noted to assist in determining potential risk factors and how we can minimise the effects of these to reduce your risk of injury in the future. Of particular note would be any soft tissue, ligament or joint injuries from the hips down.
The last part of the conversation will revolve around you and your goals for rehabilitation and what you want your knee to be able to do the following rehabilitation. Often this may not be able to be fully fleshed out in our initial consultation but it can be important to start the conversation early to ensure we are both on the same page.
It’s vital that an experienced physiotherapist conducts a thorough physical exam on your injured leg before any treatment begins. Assessing knee function early after an ACL injury is the best way to determine whether an anterior cruciate ligament rupture has occurred. If the injury was sustained more than 5 or so days ago hands-on tests may not be as reliable due to the presence of hamstring spasms resulting in false negative tests. So the earlier you get in for an assessment the better.
The knee will often present with significant swelling causing functional difficulties as well as range of motion loss. There are two commonly performed ACL tests, Lachmann’s which is the better diagnostic test, along with an anterior drawer test. A physiotherapist should perform these two hands-on tests to assess for laxity of the ACL and to determine whether there is an end feel. An end feel is often described as a stopping sensation that you will feel when you stretch a ligament to its endpoint. If this sensation is absent, the likelihood of an ACL rupture is quite high.
Other hands-on tests will include assessing other ligamentous structures such as the MCL, LCL, and PCL. Meniscus tests will also be performed to assess for the potential presence of a medial or lateral meniscus tear. A functional assessment will be the other key portion of our assessment. Determining your current functional capacity by assessing movements such as:
Following our assessment we will provide you with a diagnosis and if we believe further investigations such as an MRI I recommend you speak with your GP to obtain an MRI referral. I am able to provide a written letter to your GP providing a summary of the details of my assessment and diagnosis.
In Australia, most ACL injuries are treated with surgical management, with 90% of people opting for an anterior cruciate ligament reconstruction. Currently, though there isn’t any research that indicates that surgical reconstruction is superior to non-surgical rehabilitation in any outcome measures.
The theory of surgical reconstruction is to reinstate the lost passive stability that the ACL provides. Commonly surgeons will utilise a graft from the hamstrings but some surgeons may opt to utilise the patella tendon, ultimately this is surgeon preference in most cases. Most clients respond positively to ACL reconstructive surgery and don’t report any complications but depending upon your surgeon’s protocol you may be placed in a knee brace for a period of time following surgery.
Returning to running after ACL reconstruction will typically occur within the 12-16 week period and returning to restricted training often occurs around the 4 to the 5-month mark. I often recommend clients aim for a 12-month return to sport. 9 months is certainly possible but requires a significant investment in time into the rehabilitation that some clients with work and family commitments may not be able to make. Returning to sport prior to 9 months isn’t highly recommended due to the significant increase in the risk of re-injury due to graft maturity rates.
Non-surgical reconstruction consists of an individualised and comprehensive exercise program tailored to the individual and their goals. Non-surgical rehabilitation is commonly accepted as an ACL treatment pathway in Europe but is much less adopted in Australia with only around 10% of people undergoing non-surgical rehabilitation compared to approximately 50% in Europe. Current research and guidelines recommend undertaking a period of supervised rehabilitation for 3 to 6 months prior to determining whether surgical intervention is necessary. This is often based on whether instability sensations are present during a functional assessment of the knee or during daily life.
Non-surgical ACL rehabilitation consists of the same processes for recovery as surgical rehabilitation, you will be performing the same exercise program with the same goals and the same criteria to return to sport.
The major benefit of non-surgical rehabilitation is that you can return to sport much quicker if your body is able to adapt to not having an ACL, or, as is being found to be quite common, your body heals your ACL rupture. Some clients however may simply be unable to return to sport with non-surgical rehabilitation and my aim is to find these people as soon as possible and refer them on for a surgical opinion.
In the early rehabilitation phases, it is all about settling down the inflammatory process, maximising the range of motion, and keeping knee and leg muscles active to minimise strength losses. Hands-on techniques such as massage, dry needling, and joint mobilisations are integral to maximising mobility and maintaining the functional capacity of the knee. At home, the utilisation of ice and compression bandages to minimise the swelling build-up throughout the day is important. With regards to an exercise program the early emphasis is on light but consistent loading for range of motion as well as consistent isotonic and isometric quadriceps exercises, focusing also on the hamstrings, gluteals, and calves. We may also include seated knee extension exercises in your program.
As fun as all of the plyometric and change of direction work is, we can’t do that work if we don’t have a solid basis of strength. Developing a well-rounded strength and conditioning program not just for the knee but for you as an athlete is the next stage of your progress. I will work with you to develop a complete strength and conditioning program including a gym program and home program so that you are able to maximise your results in the minimum amount of time. This process takes time, we can’t rush strength training as magic can’t happen in 2 weeks. This stage takes commitment and consistency in training to see results. You will get out of it what you put in.
This is where it starts to get a little bit more fun. Prior to fully developing into plyometric work we will have done some introduction work prior to this to develop your movement patterns and ensure that you are nailing them. The key point I will be hammering home during the stage is technique and consistency. An athlete may be able to produce a lot of power, but if they can’t control it they will significantly increase their risk of injury. We will also be working on change of direction and multidirectional drills in this stage as well as we begin to prep you for the workload up to returning to training.
This is often the biggest portion of the rehabilitation process that I feel gets missed by clinicians and it’s integral to a good outcome. Without being able to assess and see how an athlete moves and operates on the field or court it is difficult for practitioners to truly give advice. As a mobile physio, I am at an advantage in that I am able to meet you at your nearest sporting field or court and watch and participate in field-based drills with you and we can discuss your performance right then and there. There’s no need for you to come back and see me in 3 weeks and tell me how you went because you can tell me in real-time and we can optimise and hone in on what you most need to work on to maximise your performance. All of this work is feeding in with returning you to training in a progressive and staged manner. Increasing the complexity of the environment around you by manipulating the number of players involved in a drill or increasing contact are just some of the ways we work with you and your coach to seamlessly work your way in.
The end goal for any athlete is to get out there in a competitive game. Here, we need to put all of the pieces of the puzzle together. Culminating in a return to sport assessment that includes clinical, psychological, and physical testing measures to ensure you are truly ready to return to sport. Our return to sport assessment is based upon the latest evidence and research to ensure we are providing you with the best information possible.
As a physiotherapist, I have managed many ACL clients, whether they undergo surgical reconstruction on their injured knee or opt for non-surgical management. From football players of all codes (union, league, AFL, and soccer), to basketball and netball players I have helped just about any athlete return to sport after their ACL injury.
We pride ourselves on our ACL rehabilitation program which was developed in-house that helps take anyone from day one post-injury all the way through to return to sport should that be their goal. Our program includes everything from home exercises, a gym program, a return to running program, and return to training progressions.
Each stage of the program requires you to pass certain criteria. Recent evidence has identified that criteria-based progression has shown both better results in rehabilitation and lower re-injury rates compared to time-based progressions.
Anterior cruciate ligament injuries get expensive, once you factor in potential surgical costs, time off of work, doctors’ appointments, and specialist consults, it all adds up. I genuinely believe my ACL rehabilitation package provides the best value for money in physiotherapy rehabilitation for the best results.
As part of our ACL Rehabilitation package, you get everything you will need to go from start to finish. It encompasses everything including the following:
Physiotherapy is a key factor in maximising your recovery, ensuring you return to your maximum performance on your return to sport, and ensuring you maximise your quality of life in the future. As a mobile physiotherapist, we can cover everything for you as I am not bound by the structures of a clinic. If we need to perform field-based rehabilitation we meet at a field, if we need to reassess your gym program, I will meet you at your gym. Wherever we need to be I will be there.
Our rehabilitation program includes a total of 51 physiotherapy sessions throughout the 12-month program. Why so many some may ask? This program was designed for those who want the best outcome possible and is designed to not cut any corners, following all ACL rehabilitation protocols. When you work with our clinical practice, we will leave no stone unturned through your recovery and be with you every step of the way. The amount of contact we will have throughout the 12 months will change depending upon the stage of recovery that you are at to best suit your needs and goals. We have detailed below the aims of each stage and what changes throughout the program.
ACL rehabilitation can be expensive, particularly if you are opting for surgical management. Once you account for specialist consults, surgical fees, the cost of an anaesthetist, and imaging costs it adds up, and we haven’t yet included any potential time off from work yet. We don’t believe that finances should play a role in an athlete being able to have access to the best rehabilitation possible. If you were to access this program at a regular cost it would set you back $5200, our package costs a total of $4080, a saving of over 20%. For the level of access and rehabilitation that you will receive I honestly believe it is fantastic value for money.
Now I understand that given the early costs of managing an ACL injury are quite high which is why payment plans are available. Weekly, fortnightly, or monthly payment options are available depending on what best suits your needs and capacity. I will work with you to find an option for you to access the care you desire and deserve.