The Anterior Cruiciate Ligament (ACL) is a ligament that is responsible for limiting tibial anterior translation and internal tibial rotation. Due to this it plays a big part in the stability of the knee especially in change of direction sports such as soccer, rugby and basketball.
ACL rehab has traditionally meant that surgery was needed. But emerging evidence has suggests that it may not be necessary dependent on your age and goals. There have been a bunch of athletes known to be playing elite levels of sports without an ACL such as DeJuan Blair (NFL), Peter Wallace (NRL) and even Connor McGregor (UFC) fought with a partial ACL tear (You can read the full blog on athletes who played without an ACL here)
In the route of an ACL repair, the most common graft taken in Australia is the Hamstring graft. This is where they take your hamstring tendon and essentially use it as your ‘new ACL’ which as a result compromises the hamstring. Due to the multi-factorial and significance of ACL rehab, it is recommended that the rehabilitation process is at the very minimum 9 months. However, return to sport after 9 months has shown to be associated with reduced risk of re-injury.
Starting your ACL rehab journey, if you’re going down the route of surgery, pre-habilitation (rehab before surgery) is essential.
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Phase 0 - Pre- Op Block- the pre-op phase consists of improving range, strength and reducing swelling should be the goal before surgery to improve outcomes after surgery.
Phase 1 - Baseline Block - Is the first few weeks after surgery. Any surgery is essentially trauma to the body and ACL reconstruction is no different. Whilst it’s tempting to dive right into the deep end, it’s best to let the knee settle for the first 1-2 weeks with basic range exercises, quadriceps setting drills, gait retraining, ice and compression. The main goal of this stage is to get the knee straight with full extension, reduce the swelling and maintain as much quadriceps strength as possible.
Phase 2 -Functional Block 1 and 2 - Neuromuscular control and strength. The goal of this stage is to regain strength, balance and co-ordination. An important thing to note during this phase is to keep the knee ‘quiet’. This means listening to the knee and only progress as the knee allows. his phase usually commences with easy body weight type exercises and progresses into a gym-based regime with a mixture of resistance, balance, and co-ordination exercises.
Phase 3 - Chaos Introduction - Although ACL rehabilitation should be more criteria based progressions rather than time base progressions, we usually see athletes progress into this running, agility and landings stage anywhere from 3-5 months. Again every athlete and every rehabilitation journey is different. During the commencement of this phase the knee should be swelling and pain free so that emphasis can be placed on correct technique particularly for deceleration tasks such as landing from a jump. During this phase Neuromuscular control and strength exercises should be progressed to challenge the athlete. It is important that jumping/landing technique is perfected before progressing to the next phase.
Phase 4 - Return to Training and Return to Play - Research currently suggests that return to sport should be minimum 9 months as that is when the ACL itself is completely healed. A number of things must be considered before returning the athlete to sport including the athletes confidence, the strength and stability of the knee, as well as the patterning and the biomechanics not only of the knee, but the whole body. The progress of returning to sport must also be gradual starting with restrictions and eventually without.
Phase 5 - Return to Full Performance and Injury Prevention - This is a critical phase where each athlete must continue to maintain or even improve their confidence, strength and biomechanics. A program should be given on discharge that works on plyometrics, balance and strength.
Want to learn more about ACL injuries? Check out our new ACL specific website here