So you’ve just found out that you tore your ACL last weekend and it’s now hitting home that you won’t be playing your favourite sport for a while. It’s not ideal, I know. You actually may have been better off fracturing a bone, which would mean being out for 2-3 months potentially, rather than 12 months. But you’re here now and the question you should be asking is, ‘what are my options?’. The main question that you will need to answer at some stage is, do I require surgery or not?. The answer to this question will depend on various factors, but weighting up your unique set of circumstances is key to getting closer to an answer.
The following 10 facts outline some of the key information that you should know before deciding on Anterior Cruciate Ligament Reconstructive (ACLR) Surgery.
#1 Rehabilitation will last a minimum of 365 days
Rehabilitation following ACLR surgery is long, it’s tough and it requires serious effort and dedication. Make sure that you know what to expect before signing the dotted line. Failing to rehab properly following surgery, will lead to a significant increased risk of future knee injury (and that risk is for either knee by the way).
#2 Return to sport before 9 months 'at your pearl'
Unless you’re an elite athlete (i.e. being paid to play sport full time, receive daily medical care and drink coffees all afternoon), you will return to sport no sooner than 12 months following surgery. One paper found that "returning to sport before 9 months following ACLR, was associated with a 7-fold increased rate of sustaining a second ACL injury, compared to those who delay surgery, in young athletes" (Beischer et al, 2020).
#3 12 is the magic number (it seems, or is it !!)
Everyone will reach the 12-month mark post-surgery. However, if you haven’t put the work in over those months, then you simply won’t pass the exit criteria to return back to sport. In this case, the number 12 means absolutely nothing (other than being ex-All Black Legend, Ma'a Nonu's old jersey number - rugby reference).
#4 If you run in straight lines, maybe think twice about surgery
If your sport involves running 5km, 10km or ½ marathons, and does not involve regular change of direction work, then conservative management (i.e. no surgery) may be a suitable option for you initially. With sufficient strengthening, you may find that you cope fine without your ACL (i.e. in the research world, we would call you a coper).
#5 Surgery is definitely an option for athletes involved in pivoting sports
Although a small number of individuals have returned to pivoting sports without ACL surgery, these cases are few and far between. With no ligament to stabilise your knee when pivoting, excessive tibial translation and rotation is likely to occur. This can may lead to further meniscal or osteo-chondral injuries.
#6 The ACL can potentially heal......say what!!!
Until recently, it was thought that the ACL could not heal at all without surgery. Relatively new research using MRI imaging has thrown this fact into doubt (Costa-Praz et al, 2012). Future research is required though, to determine the exact extent of ACL healing and how this would affect the need for surgery in some cases.
#7 You think you’re strong, think again!
You have 12 months to work your way through the rehabilitation framework. In the mid-to-late stages you will focus on muscular strength and power, amongst other performance variables. But what you think is strong, may not be strong enough. Discuss with your physio what markers you need to hit so you know how strong you actually need to be. In one research paper, individuals had lower quadricep strength in their injured leg up to four years post-surgery, when compared to matched healthy controls (Brown, Marinko, LaValley & Kumar, 2021).
#8 The upside of rehab.....enjoy the process!
Although not rupturing your ACL in the first place would have been better. The fact is, you are here now. Think of rehabilitation as an opportunity to address other areas that require work. This could involve improving capacities, skills, body composition or rehabbing old injuries correctly. You should return to sport in a better place physically and psychologically than you were before.
#9 This is not my first rodeo
If this happens to be your 2nd or even 3rd ACL injury, i.e. you’ve ruptured your ACL graft, then deciding on whether to go under the knife again will depend on multiple factors. You should have a conversation with your consultant regarding your options. Speaking of rodeos, I am surprisingly good at staying on the 'bucking bronco'...who knew!
#10 Only fools rush in
You need to know what to look for when deciding on a physio to take you through the lengthy rehabilitation process. Suggestions of what to look for in a physio or physio clinic include:
Extensive experience in ACL rehabilitation
A strength and conditioning qualification
Supervised gym-based sessions
Supervised pitch-based rehabilitation runs
Regularly updated gym and pitch-based programming
Video analysis and feedback of running drills & running mechanics
Access to testing, or be referred elsewhere as necessary (i.e. Isokinetic testing)
Know thy sport (i.e. ensure your physio knows the physical requirements of the sport)
Knowledge of relevant and up to date ACL research
Motivating, inspiring and fully present at every session
"When a 'return to sport' battery of tests was utilised, along with testing throughout rehabilitation, subsequent ACL injury rates were reported to be <10%."
King et al (2020)
So, there you have it. I honestly could have written twenty more points, but this blog post is a good starting point for anyone who finds themselves in the unfortunate place of reading this article (i.e. you're currently icing a big swollen knee). Each and every ACL injury and athlete is different, so get as much information as possible to help make an informed decision.
If you would like to know more or you have questions, drop me an email at firstname.lastname@example.org. Alternatively, book online following the link below. I would love to take you through the ACL rehab journey and back to the sport that you love playing.
Start your rehab today!
Beischer et al (2020). Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. Journal of Orthopaedic and Sports Physical Therapy. 50(2):83-90. doi: 10.2519/jospt.2020.9071
Brown, Marinko, LaValley & Kumar (2021). Quadriceps Strength After Anterior Cruciate Ligament Reconstruction Compared With Uninjured Matched Controls: A Systematic Review and Meta-analysis. 9(4). doi: 10.1177/2325967121991534