The most commonly injured ligament within the knee is the Anterior Cruciate Ligament. The ACL attaches on the anterior intercondylar of the tibia and ascends posteriorly to the lateral area of the femur, crossing with the Posterior Crucial Ligament (PCL) in the intercondylar region with the role of preventing anterior displacement of the tibia relative to the femur.
ACL injury can occur as a result of both contact and non-contact injuries during acceleration of deceleration while twisting. An ACL injury was once considered to be a career ending injury with athletes struggling to return to the same level of play they were previously competing. Although we have come a long way in developing rehabilitation and return to sport programs for ACL injuries there is currently no consensus on what is considered the “ideal program” with individual intrinsic and extrinsic factors strongly influencing decisions.
Nearly two-thirds of ACL injury is the result of a non-contact moment with majority of those occurring due to a “knee-in and toe-out” dynamic where the athlete attempts a direction change while the foot stays firmly planted to the surface. Contact injuries will result from the knee suffering valgus stress and typically occur in sports such as rugby, football, basketball and skiing. These types of injuries will coincide with bone bruising and meniscus trauma in 66% – 92% of cases.
As mentioned above, an ACL injury will occur with a pivoting moment at the time of accelerating or decelerating. Additionally, a patient may hear a popping or clicking at the time of the injury. Swelling will occur around the knee and clinically will display a positive pivot shift test with the loss of knee extension and Lachman’s Test. It is highly suggested that the use of MRI be used for a diagnosis of the extent of the injury to aid in the future management of the condition.
The aim of pre-operative rehabilitation is to develop full pre-injury range of motion, increase proprioception at the knee joint, neuromuscular activation patterns and of course the reduction of swelling, bruising and pain.
This is primarily achieved by a well-designed and implemented physiotherapy based rehabilitation program. Strengthening the muscles which cross the knee through basic activation and control exercises will help to stabilize the knee and reduce the possibility of early onset arthritis.
A cross-sectional study by Mikkelsen et al, 2016, found that patients who completed a 10-repetition maximum load knee extension exercise for a single set until muscular contraction failure were shown to have increases in the voluntary activation of the quadriceps muscle. This is seen as an imperative neuromuscular adaption for the enhanced recovery of functional performance. Additionally, developing this ability post-surgical intervention is also necessary due to the inhibited motor units from the surgical trauma and its physiological impact.
The evidence for rehabilitation pre-surgery has become stronger over the last eight years as it can physically and mentally prepare a patient for the impact of ACL reconstruction.
With the stronger evidence for pre-operative rehabilitation also came the development of more aggressive post-operative rehabilitation as opposed to the previous conservative approaches. Similar to the aims of the pre-operative rehabilitation programs, post-op programs aim to strengthen the knee joint and improve the proprioception around the joint. The most successful rehabilitation programs have been those which in compass home based activities and clinical setting elements. As well as the utilization of both open and closed chain activities specific to the muscles cross the knee joint.
There are multiple intrinsic and extrinsic factor which may impact an athletes return to sports however; most are expected to return to training in 6 -12months. A phased physiotherapy ACL program my look similar to the following:
PART ONE: Reduce swelling, return to full weight bearing and increase passive knee range of motion.
PART TWO: Improve proprioception, increase muscle strength in the quads and hamstrings while increasing passive knee extension.
PART THREE: Achieve better neuromuscular control and optimal strength within the lower limb.
PART FOUR: Return to sport specific exercises, movement patterns and multi-tasking activities while maintaining and improving stability of the knee through proprioceptive exercises.
All rehabilitative programs should be supported by as much education on the condition as possible so the patient is fully informed and on-board with their prescribed activities. This also helps to develop and personalize realistic goals which can maintain patient motivation and continue their compliance beyond their pre-injury physical state.
Until Next Time
Director/ Chief Editor
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