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ACL rehab monster walk Sheddon Physio Sports Clinic Oakville Mississauga

ACL Rehabilitation: What you Knee’d to know.

ACL injuries continue to be one of the most common and devastating sports injuries. Despite the long and extensive rehabilitation process, rates of re-injury range from 3-22% for an operated ACL and 3-24% for the contralateral ACL in the first 5 years after surgery. Due to these numbers, many athletes never return to their sport. A recent systematic review was published by a group of ACL experts in order to help develop evidence-based guidelines for rehabilitation following ACL reconstruction. Topics they examined included:

  1. Preoperative factors that can effect recovery;
  2. Effectiveness of physical therapy;
  3. Benefits of specific exercises;
  4. Return to play guidelines;
  5. Risk for re-injury.

Preoperative factors

Many athletes will start doing physiotherapy prior to surgery in order to strengthen the knee. The above researchers found that quadriceps weakness, as well as extension deficit (not being able to reach 0 degrees of extension or more) prior to surgery, will have a negative consequence on the rehabilitation process post-surgery. Don’t tell yourself these issues will get “fixed” with surgery, prehab is essential to guarantee a successful post-surgery outcome.

Strength and Neuromuscular training

There are many exercise programs designed for ACL injuries. What exactly should you be focusing on? Strengthening, proprioception and neuromuscular training are vital, especially for return to sport. For some ideas on where you should be focusing, please read our earlier blog, here.


Most physiotherapy clinics use a variety of different modalities with their patients, but which ones are most useful post ACL?

Muscle stimulation has been shown to be effective when combined with exercise. The muscle stimulation will help activate the muscles, which are either too weak to engage, or are inhibited due to pain and/or swelling. The machine helps turn on the muscle during exercise, and the patient is encouraged to work with it to help regain strength. In addition, cryotherapy has been shown to help with acute pain and swelling.

Return to Play

Return to sport rehabilitation should focus on plyometrics and agility, as well as take off and landing mechanics. A series of different tests need to be performed in order to determine readiness to return to sport. These tests should assess strength, balance, and proprioception, as well as functional sport patterns. It is essential that both the injured and uninjured knees be tested, due to the high rate of injury to the opposite knee with return to sport.

Risk of Re-injury

Rates of re-injury range from 3-24% for either the surgical or non-surgical knee, with some researchers claiming that the opposite knee is twice as likely to get injured upon return to sport.  Other studies have shown that age is a major predictor of recurrent ACL injuries, with young athletes (under 20) having a rate of 20-40% re-injury. Other risk factors include:

  • Poor neuromuscular function and biomechanics;
  • Higher activity level;
  • Allographs vs. autographs.

Whether you have just been diagnosed with an ACL tear and you’re waiting for surgery, or you’ve undergone the surgery and are working on rehabilitation, the staff at SPSC can help guide you along the way to ensure a full and successful return to sport.

Van Melick et al., (2016). Evidence-based clinical practice update: Practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. BJOSM.

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Test for high risk for ACL injury - Sheddon Physio Sports Clinic Oakville Mississauga

Single Leg Squats: Singles out athletes at risk for ACL injuries

ACL tears are one of the most common and devastating sporting injuries that athletes encounter. Following surgery and return to sport, rates of re-injury, either to the same knee, or opposite knee, are estimated at around 25%. As a result, many athletes fear re-injury upon returning to sport post-surgery, and research has shown that less than 50% of athletes will actually return to their sport. Some factors which have been associated with re-injury include:

  • Younger age (under 20-years old);
  • Higher activity level;
  • Female gender;
  • Returning to sport without proper conditioning:
    • Lack of strength (core and lower limb – on the injured and uninjured side);
    • Lack of neuromuscular control and proprioception

From this list there is really only one factor that can be modified and controlled, that  of “Proper Rehabilitation and Conditioning.” Research has been focused greatly on ACL rehabilitation programs, with a particular interest in neuromuscular control.

ACL injuries have been shown to result in decreased neuromuscular control, or functional stability of the knee joint, due to damage to mechanoreceptors. A healthy ACL has mechanoreceptors which help with muscle control, stability and proprioception. When an ACL is injured, so are these mechanoreceptors, which is one reason individuals commonly have lack of muscle stability and control post injury. New research has shown that damage to the mechanoreceptors of injured ACLs can also affect the non-injured side, due to inactivity and re-organization in the brain. There is also a possibility that neuromuscular control was lacking in both knees prior to injury, and may have actually been a cause of the initial injury. A current study by Culvenor et al., (2016) sought to examine this theory by looking at neuromuscular control post-ACL repair in the injured and uninjured leg, in order to help identify future injury risk. The study used a single leg squat as their neuromuscular control task, since it is one of the most functional movements seen in sports, as well as a common position which can lead to re-injury, if strength and motor control is impaired. Their results demonstrated that participants with ACL injury had significantly worse neuromuscular control, as seen with the single leg squat, in both their surgical knee and uninjured knee versus the healthy control group. 

These results are consistent with past researchers who have shown neuromuscular control issues post-ACL injury/repair. However, the current study also highlighted the fact that the non-injured knee is generally affected as well. Many athletes focus their rehabilitation solely on their injured knee following ACL repair. Yet, a large majority of individuals will return to sport and actually injure their non-affected side. More specifically, research has shown that females are more at risk for injury to the non-surgical ACL, while males are more at risk for re-injury to the same ACL. As such, one of the most effective strategies to prevent secondary ACL injuries is to strengthen both knees prior to returning to sport, with a particular emphasis on exercises that focus on neuromuscular control.

If you want to know more about neuromuscular exercises post-ACL injury, the team at Sheddon Physiotherapy and Sports Clinic can help assess and prescribe the right exercises for you.

Take Home Message

  • Neuromuscular control should be assessed and treated in both knees to prevent re-injury post ACL repair;
  • Single leg exercises such as single leg squats and single leg plyometrics are essential  to maximize performance and reduce the risk of reinjury to either knee.

Culvenor et al., (2016). Dynamic single leg postural control is impaired bilaterally following anterior cruciate ligament reconstruction: Implications for reinjury risk. Journal of Orthopaedic Physical Therapy. 46, 357-364.

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post acl tear treatement physiotherapy sports clinic oakville mississauga

Avoiding Osteoarthritis Post-ACL Tear

Osteoarthritis is a condition caused by progressive deterioration of cartilage or even the entire joint.  When the cartilage becomes softened, it will begin to wear away causing bones to rub against one and other. Our cartilage is what normally absorbs the stress. Osteoarthritis causes pain, stiffness, and sometimes a limitation in movement. Most common places of discomfort are areas where large biomechanical forces are loaded including the vertebrae, knees, and hips. Those who were athletes from a young age and have had a serious injury (like ACL tears) are more prone to developing osteoarthritis due to extended years of wear and tear on their joints.

In recent years studies have shown an incline of people who are affected by osteoarthritis between the young people, particularly women.

The major factor that increases one’s chances of developing osteoarthritis is experiencing a serious injury, such as an ACL tear.

Those who suffer from osteoarthritis are always recommended to keep your body moving. Simply taking a walk around your neighborhood can reduce pain. Try a new and fun activity like yoga. Strengthening exercises can help build muscle around the affected joints, which will ease the burden placed on these joints, thereby reducing pain. Range-of-motion exercises continue to help maintain and improve joint flexibility and reduce stiffness. Another good technique is taking up an aerobic exercises that will help with energy levels and improving stamina.

As younger and younger athletes are developing osteoarthritis, it is important to learn that the answer is not to stay in bed but to move, move, move. Contact your Sheddon Therapist and see which exercises are right for you!

Lohmander, L. S., Östenberg, A., Englund, M., & Roos, H. (2004). High prevalence of knee osteoarthritis, pain, and functional limitations in female soccer players twelve years after anterior cruciate ligament injury. Arthritis & Rheumatism50(10), 3145-3152.

 By Jessica Osmond

Can We Help You Prevent An ACL Injury? YES!

As many as 1 in 20 collegiate-level and 1 in 50 high school-level athletes sustain an anterior cruciate ligament (ACL) injury during any given year of varsity sports. But what can be done to prevent this? It has been shown through research that preventative rehabilitation and the brain/body training (neuromuscular) reduce ACL risk by 24% to 82%. These numbers are higher in females than in males due to anatomical differences – which means that women are more at risk of injury but also more likely (with this program) to be better protected from the ACL tearing in high-risk landing and cutting sports like soccer, basketball, volleyball, and hockey.

Most ACL injuries occur by noncontact mechanisms, during deceleration from a landing or making a lateral pivot. Neuromuscular training is effective in the reduction of ACL injury risk in athletes by helping correct 3 neuromuscular imbalances that may put them at risk of ACL injury. These potentially correctable neuromuscular imbalances—ligament dominance (increased load on the knee joint), quadriceps dominance (decreased knee flexor recruitment and strength), leg dominance (increased leg-to-leg differences in muscle coordination and strength – may decrease dynamic knee stability and lead to ACL injury risk.

Are Female Athletes Really at Higher Risk for ACL Injuries?

Female athletes are 2 to 10 times more likely to sustain an ACL injury compared to male athletes playing the same landing and cutting sports.
U.S. High school and collegiate athletics contributes to >50,000 ACL injuries in female athletes each year. An estimated 1 in every 50 high school female athletes will sustain an ACL tear. This leads to a greater number of surgical interventions to reconstruct and rehabilitate the ACL in these athletes.

More than 50% of the patients show early signs of irreversible osteoarthritis within 10 years of ACL reconstruction, particularly female athletes. This is in addition to the traumatic effect to these individuals of the potential loss of entire seasons of sports participation, possible scholarship funding, and potential decreased performance in the academic arena.
A major theory to account for higher knee injury incidence in female athletes is that neuromuscular imbalances, due to training deficiencies, developmental differences, or perhaps hormonal influences, lead to higher injury rates. Other variables that may be contributory include lower limb alignment as well as biomechanics and kinematics, overall ligament size and strength, and muscular fatigue over a given length of time.

Does Body/Brain (Neuromuscular) Training Decrease the Incidence of ACL Injury?

The majority of published studies show that there is a 50% decrease in injury with proper training that targets the knee balance system and strength into abnormal positions.

How Does Neuromuscular Training Decrease ACL Injury?

Four imbalances are observed (more often in female than male athletes). The first observed neuromuscular imbalance is the tendency for ligament dominance. This means that the athlete has a tendency to be stopped by ligament and not muscle when at the end of joint range. The lack of muscular control of the joint leads to an increased knocked knee position, increased force, and high torque at the knee and ACL.

Another imbalance is termed quadriceps dominance. With quadriceps dominance, athletes activate their quads more than their hamstings when using the knee muscles. The hamstrings are typically used to control the stress on the ligament and therefore, without it working its fullest, the quads pull very hard on the ligament.

A third imbalance is leg dominance. Those who tend to be more dominant on one side versus the other place both the weaker, less-coordinated limb and the stronger limb at increased risk of ACL injury. The weaker limb is compromised in its ability to control forces and the stronger one may generate forces too high for it to control.

So What Do We Do To Prevent This?

The goal of this ACL Prevention Program is to avoid injury by teaching athletes strategies to avoid vulnerable positions, improve strength and flexibility, and improve proprioception. Those of us fortunate enough to be involved in youth, high school, and collegiate athletics should pass this information on to our sports medicine team colleagues whenever possible.

The Ontario Soccer Association has put together a program for soccer players that are healthy to minimize their risk of injury. Some of which can be seen in this video below:

Remember that not this program is not for everyone, it is a good idea to talk to your therapist to see what other factors need to be added or modified to help make this program specific to your needs.

The Team at Sheddon Physiotherapy and Sports Clinic can help you understand how to prevent these injuries and what exercises can be done to maintain a healthy joint in the future.

By Dana Clark