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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.

Modalities

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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