CAN I GET BACK TO MY GAME?

Patience is the key to success they say. However, prolonged conservative management for athletes injured with ACL is psychologically taxing and is assumed to keep them out of the field for a long. Hence, often the choice treatment is a surgical ACL repair. However, researchers are studying and deriving varied methods for managing the ACL well.

Managing the ACL injury

Not every individual is comfortable going under the knife. The line of treatment may differ based on the nature and severity of the injury. The individual’s occupation, lifestyle, activity levels and goals should also be taken into consideration while opting for the treatment approach. A detailed discussion with your doctor and physiotherapist would make it easier for you to choose.

Conservative Management

If not a surgical approach, conservative management would be the choice. Not intervening with any rehabilitation will only keep exposing this weak link thereby increasing the symptoms. Hence, a structured protocol for managing this injury conservatively becomes essential. 

Recently, Filbay et al. (2023) concluded the use of a Cross Bracing Protocol to have enhanced healing of a torn ACL on a 3-month MRI. The protocol involved bracing the knee at 90 degrees for 4 weeks followed by bracing with increased range for another 6 weeks. This was done along with a combination of exercises progressed with weight bearing and return to sport depending on the strength and stability. However, this research has limitations considering the grade of injury and duration. Further research is required to establish this non-surgical treatment protocol to have any long-term effects.

Individuals with low-intensity activities and mild symptoms respond well to physical therapy. A grade 1 ACL injury has shown a good prognosis whilst a grade 2 or 3 injury in athletes needs to be well considered. A conservative rehabilitation approach focuses on achieving a full range of motion ROM, regaining muscle control, improving muscle strength in the entire kinetic chain and regaining or retraining sporting movements.

Depending on the severity, functionality and goals of the patients, surgeons may recommend a pre-habilitation program before considering the surgery. This has been seen to have potential benefits in improving neuromuscular and self-reported knee function in patients post-surgical.

Surgical Management

Restoring stability and early function are primary objectives in opting for ACL reconstruction (ACLR) surgery. The torn ligament is replaced or reconstructed using an Allograft (cadaver or external graft) or Autograft (own body’s tissue). Both seem to be relatively safe out of which autografts are the most commonly used for reconstruction.

Graft selection is based on numerous factors and should be individualized based on the athlete’s age, anatomy, goals and expectations. A bone-to-bone (BTB) graft is considered to be the strongest autograft. Another commonly used graft is from the Semitendinosus (Hamstring) tendon. Other grafts used are the Quadriceps tendon and TA tendon graft. The selection of the graft may vary the ACLR rehabilitation process and duration of return to play.

A rigorous and accelerated rehab approach post ACLR aims to restore the previous function, strength, ROM and proprioception.

Return to Sport

There is no universal timeline of return to sport but a definitive comeback is possible if the athlete is compliant enough throughout the rehabilitation process. A multidisciplinary team approach throughout al. the phases of rehabilitation accelerates RTS. However, it is highly individualistic when an athlete returns to the field. A time span of roughly ranging from 9-12 months is required for the athlete to fully return to action depending on the sport played, graft type and physical ability. However, a recent study by Waldron et al, 2020 stated approximately 80% of athletes with ACLR return to some type of sport but only 65% return to pre-injury participation level and 55% return to competitive sport.  

Thus, a structured rehab protocol focusing on all parameters including strength, stability, mobility, balance, joint proprioception, speed, agility and sport-specific movement training becomes extremely important.