VKB Recovery
April 5, 2022
The rupture of the anterior cruciate ligament (ACL) is a very common injury, especially among athletes. In our first blog on "Rehabilitation and Prevention of the Anterior Cruciate Ligament," we delve into the anatomy of the knee and its structures. In our second blog on this topic, we explore in greater depth the incidence, costs, and consequences of an ACL rupture. At the same time, risk factors and injury mechanisms are described in more detail.
In this blog, we want to focus on the treatment and rehabilitation after an anterior cruciate ligament injury. The treatment plans for isolated ACL injuries and combined injuries with meniscus or collateral ligaments are quite similar. However, we are focusing here on an isolated ACL injury.
Following the injury, athletes generally have three options. Which path is chosen is discussed and carefully weighed with the treating physician based on the athlete's individual needs and requirements:
Direct surgery
Conservative treatment
Initial conservative treatment with surgical reconstruction if needed
The literature recommends that athletes who wish to return to their high-risk sports undergo surgery with reconstruction of the torn ligament.
Successful ACL rehabilitation, both after reconstruction and without surgical intervention, is a demanding and lengthy challenge that requires a lot of patience and intensive outpatient therapy. A successful surgery is ideally just the foundation for an optimal healing process. However, without rehabilitation, returning to sports is inconceivable.
During wound healing and throughout rehabilitation, various physiotherapeutic goals are pursued:
Graft-bone healing of the implant
(Revascularization of the cruciate ligament)
Pain relief & reduction of swelling
Maintaining (restoring) mobility in both tibiofemoral and patellofemoral joints
Restoration of proprioception and strength
Freedom from discomfort in daily activities
Return to fitness in the respective sport
The optimal ACL rehabilitation must be individually adapted to the patient, the current state of the injury, and the personal ultimate goals of the athlete, as the body reacts differently to such an intervention.
In addition to optimal rehabilitation, understandable and solid patient education is also essential.
ACL Rehabilitation
The optimal ACL rehabilitation begins immediately after the trauma with preoperative rehabilitation. The goal of this phase is to bring the patients' baseline level and the injured structure to the highest possible level before the operation. This will significantly influence the rehabilitation process after surgery. In this phase, emphasis is placed on knee extension and joint mobility, but the strength and power of the quadriceps muscle are also of great importance. Specifically, the vastus medialis should be activatable by the patient and actively promoted through specific exercises.
Strengthening the quadriceps before surgery seems extremely important. Studies have shown that a 20% deficit in quadriceps strength before surgery can result in a significant deficit in quadriceps strength for up to 2 years [1].
The second phase of rehabilitation starts immediately after the operation. During this time, swelling and pain are the main focus. At the same time, muscle activation is worked on, as it should ensure active control of the knee as quickly as possible. Once the knee can be actively stabilized during everyday movements and a normal gait pattern is present, forearm crutches can usually be dispensed with. Our physiotherapists at BodyLab will be happy to provide you with personal and individual advice.
From now on, it is a matter of controlling and adequately increasing the load on the knee as well as regaining full mobility. The focus is on mobility and coordination of the lower limbs. Although primarily the affected leg is trained, both legs should always be involved in the training. The muscles and coordination of the unaffected leg also regress during the immobilization period. Until full weight-bearing is achieved, forearm crutches may occasionally be used as aids.
Once full weight-bearing is achieved in everyday life, the patient has reached a very important milestone in rehabilitation! However, there is still a significant deficit in terms of strength, coordination, endurance, and load resistance. Therefore, in the fourth phase, work on strengthening and coordination continues. This is now done with more weight and increasingly with sport-specific loads.
In the final phase, it is about sports-specific development and full load-bearing in sports with body contact and high-risk movements. Here athletes will primarily train at the neuromuscular level. This includes jump exercises, maximum strength, and explosive power. High weights and rapid movements are used. Until this point, a solid base is a must, as the structures otherwise cannot withstand the load.
Conclusion
The injury of the anterior cruciate ligament is a serious injury that can be treated in various ways. Whether conservatively or through surgery, subsequent rehabilitation, which extends over several months, is indispensable. A diverse and individually adapted therapy supports the body in the healing process and helps the affected person regain their daily functions. The phases mentioned above are a guideline and should not be considered a rigid program. Through consistent rehabilitation and disciplined build-up training, 83% of elite athletes return to their sport following ACL reconstruction and participate in their first official competition after 6 to 13 months [3].
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References
Nicky van Melick, Robert E H van Cingel, Frans Brooijmans….2016 Review
[2] Treatment protocol and return to sports after cruciate ligament reconstruction – Vavken, Sadoghi, Valderrabano, Pagenstert
C. H. Lai, C. L. Ardern, J. A. Feller, and K. E. Webster
Br. J. Sports Med., vol. 52, no. 2, pp. 128–138, 2018.
Image Credit
No machine-readable author provided. Lucarm84 assumed (based on copyright claims)., Cruciate Ligaments, marked as public domain, details on Wikimedia Commons
