ACL (Part 2) – Rehabilitation & The Melbourne ACL guide

In Part 1 we learned about the anterior cruciate ligament (ACL) and what is does, how one might sustain an ACL injury and the management options following an ACL injury. Part 2 focuses on rehabilitation after ACL surgery and specifically the Melbourne ACL Rehabilitation Guide. Unfortunately, only 5% of ACL reconstruction patients receive evidence-based rehabilitation guidelines following surgery (Grindem et al. 2018). However, at EBTC we utilise the evidence-based Melbourne Guide with all our ACL patients. Designed by Mick Hughes and Randall Cooper, two renowned physiotherapists based in Melbourne, Australia, the Melbourne Guide adopts a criteria-based rather than a timeline-based approach to ACL rehabilitation, ensuring that athletes are truly ready to return to sport after ACL reconstruction. The advantage of this approach is that it recognises that different people progress at different rates for a variety of reasons.

The Melbourne Guide has six phases (including a pre-op phase) to ensure a logical, systematic and safe progression of rehabilitation from initial preparation for surgery all the way through to return-to-play. At the end of each phase, a battery of tests will determine your readiness to progress to the next phase of rehabilitation.

Pre-op Phase: Injury Recovery and Readiness for Surgery

Although athletes will typically want to undergo surgery at the earliest opportunity in order to minimise time away from sport or activity, it is advised that athletes undergo a period of rehabilitation prior to surgery. Recent research indicates that those who carry out a period of pre-operative rehabilitation focusing on range of movement and strength have better outcomes that those who don’t (Kim et al. 2015). 

Your physiotherapist at EBTC can provide you with advice on recovery from your initial ACL injury and will guide you through this pre-operative phase, optimising your readiness for surgery.

Phase 1: Recovery from Surgery

The primary goal immediately after surgery is to get the knee straight as soon as possible, ideally within the first 2-3 weeks. 

Other important goals include settling the swelling as well as initiating quadriceps muscle activation. These goals will generally be achieved through gentle range of motion exercises, quadriceps setting exercises and regular icing, compression and elevation of the knee. 

Your physiotherapist at EBTC will help determine the most appropriate exercises for you at the phase and ensure that you meet the requisite goals before progression to phase 2.

Phase 2: Strength and Neuromuscular Control

Phase 2 accounts for a considerable portion of the ACL rehabilitation journey as the patient works to rebuild strength and control around the knee. 

The primary goals in this phase include regaining muscle strength, balance and co-ordination. 

Quadriceps strengthening is particularly crucial in this phase, with research illustrating that for every 1% increase in quad strength symmetry there is a 3% decrease in reinjury risk (Grindem et al. 2016). 

Typical exercises in this phase may include squats, step-ups, calf raises, balance exercises and non-impact conditioning such as walking, cycling and swimming. 

It is vital that appropriate exercises are chosen and that your rehabilitation is appropriately progressed throughout this phase. For example, the quadriceps must be trained within restricted range limits for the first 3 months post-surgery while the ACL graft is healing (Luque-Seron and Medina-Porqueres 2016). 

Your physiotherapist at EBTC will ensure that you are provided with an individualised and progressive rehabilitation programme. They will also ensure that all exercises are being carried out with correct technique, which is particular important as research highlights that ACL patients often demonstrate compensatory movement strategies for as long as five months post-surgery (Sigward et al. 2018). Your symptoms will also be monitored carefully throughout your rehabilitation, thereby allowing you to safely challenge your knee to ensure that you are ready for more challenging functional tasks in the later phases of rehabilitation. 

Mid-Stage Rehab Vid Examples:

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ACL Rehab Must Dos ——- There are a few must dos when it comes to ACL rehab. While I could post a long list, I’m choosing to pick the two most important after full range of motion is attained. In my opinion, the two most important things strengthening and neuromuscular control. These two components should ALWAYS be a part of rehab (and injury reduction) regardless of what phase of rehab they’re in. ——- Progressive strengthening should always be incorporated in rehab. When I get patients from other facilities, they are often surprised at just how challenging rehab should be. I believe every session should be challenging and if you’re rehabbing and aren’t being challenged, find yourself a new therapist. I personally believe many PTs aren’t doing enough loading and continue to do the repetitive mundane exercises that don’t keep athletes engaged. ——- Neuromuscular control is also a key component of rehab and injury reduction. Essentially, it’s the bodies ability to control itself through different tasks. As soon as they’re physically ready, I have my patient perform plyometrics every session to address neuromuscular control. I want them demonstrate good control during plyometrics which involves trunk, hip, knee and foot control. ——- Here are a few exercises I like to use regularly in rehab. I will be posting part 2 tomorrow. 1️⃣ Eccentric rear foot elevated split squats – one of my favorite single leg quad strengthening exercises. I’m doing these at an eccentric tempo and a pause at the bottom. The tempo change makes it extremely more challenging. 2️⃣ Single leg hamstring curls – I’m using a sorinex glute hamstring roller and again focusing on eccentrics. 3️⃣ Alternate forward bounding – this addresses neuromuscular control. I have a partial ACL tear on my left and you can see I have a harder time landing on that leg. #WesleyTalksACLs ——- 🙌🏼Tag someone who could use these exercises! 👍 Like and save if you found it helpful! 🤷🏼‍♂️ Post questions or comments below!👇

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Phase 3: Running, Agility and Landings

Given the fact that the majority of ACL injuries occur whilst running, twisting, jumping or landing, Phase 3 is a critical component of ACL rehabilitation.

Provided you have demonstrated the requisite strength levels in Phase 2, Phase 3 will seek to introduce impact forces such as running, turning, jumping and landing as you edge closer to returning to sport.

Due to the demanding nature of these tasks on the body and knee joint, rehabilitation must be progressed slowly and carefully whilst listening to the body’s response throughout this phase. Again, technique is vital in this phase particularly with respect to hopping, landing and cutting. 

Exercises will begin as pre-planned runs, jumps and turns but in later stages will incorporate reactive agility drills and landings with perturbations, to prepare the body for the unpredictable and often chaotic demands of sport. 

Athletes are often guilty of stopping their rehabilitation at this stage once they are back running and are pain-free. However, it is fair to say that the later stages of rehabilitation are arguably the most important in order to reduce the likelihood of re-injury and to ensure a successful return to sport, as well as minimising the risk of osteoarthritis in later years (Thorstensson et al. 2004).

Your physiotherapist at EBTC will monitor your progression and prescribe the correct exercises for you at the right time throughout this phase.

Advanced Rehab Vid Examples:

Phase 4: Return to Sport

When implemented correctly, Phase 4 of rehabilitation should be highly individualised and begin to look quite similar to the athlete’s regular training activity prior to their injury. 

Focus in this phase is placed not only in the athlete’s physical readiness to return to sport but also their psychological readiness, which recent research is highlighting as increasingly important (Paterno et al. 2017). 

As for the question as to when the person is ready to return to sport after an ACL reconstruction, although we do not adopt a timeline-based approach we at EBTC would be strongly aligned with current research suggesting a minimum of 9 months, ideally waiting approximately 12 months before returning to sport. A critical piece of research highlights that the risk of ACL re-injury was reduced by a staggering 51% for every month return-to-play was delayed until 9 months post-surgery (Grindem et al. 2016). 

A battery of subjective and objective tests provide a criteria-based recommendation as to an athletes physical and psychological readiness to return to sport.

Research highlights that 38% of those who failed return-to-play criteria suffered re-injury, in comparison to only 6% of those who passed (Grindem et al. 2016). 

Unfortunately it is impossible to prevent all injuries in sport, however your physiotherapist at EBTC will do everything possible to minimise this risk as much as possible.R

Phase 5: Prevention of Re-injury

The final stage of the Melbourne ACL Rehabilitation Guide aims to mitigate the risk of ACL re-injury by incorporating an ongoing ACL injury prevention programme. Research shows that injury prevention programmes reduce ACL injury risk by 50% (Webster and Hewett 2018). 

This programme will generally include strengthening, balance and plyometric exercises that are carried out prior to every training session and games.

Upon your return-to-sport and inevitable discharge from the clinic your physiotherapist at EBTC can help you implement an ongoing ACL injury prevention programme to minimise your risk of re-injury in the future.

Booking an appointment

If you would like to book an appointment with Mark Durcan – chartered physiotherapist specialising in lower limb rehabilitation, you can call the clinic on 091 727777 or get in touch via the contact page.