ACL Rehabs, Where Are We Going Wrong?

The Anterior Cruciate Ligament or better known as the ACL, is one of two cruciate ligaments in the knee. The ACLs responsibility within the joint is to limit excessive range of motion and most importantly, anterior tibial displacement at 30 & 90 degrees of knee flexion (2). It is an extremely common injury in sports requiring lot’s of changing direction, such as soccer. There is approximately 100 000 to 200 000 ACL ruptures every year in the United States alone. Think of that fact for a second.


At ORKA Performance, we often specialize in return to sport injury rehabilitation and a large portion of our rehabbing athletes are coming back from an ACL reconstruction. ACL injuries at the amateur level seem to follow the same trend. Get injured, see physio/doc, wait for surgery, follow surgical centre return to sport program, return to play, re-injure ACL, start all over again. If this second injury occurs, this athlete is now out for more than 3 years when you add up wait times for surgery in Canada and following the general trend of rehabbing for 1 year. This puts a huge strain in the athletes development pathway.


Where are we going wrong in ACL Rehabilitation?


We simply can not create a one sized fits all approach for ACL rehabs. These cookie cutter programs that come out of surgical centres, simply don’t take into enough consideration the four corners of a sport. Physical, Technical, Tactical, and Psychological. Sometimes we get so caught up in the physical corner that the other corners are unexplored. This puts our athletes at risk when they return to sport. When I look back as an S&C coach on every ACL rehab that I have worked on in my career, EVERY SINGLE ONE WAS DIFFERENT. This comes down to a million questions. What was pre-op programming like? What graft they did use? Any other complications such as meniscal damage? When was ROM restored? What’s their perception of pain? What position are they returning to? Are they confident returning to sport? And these are only a few of the questions we as practitioners need to ask.


There is many resources available on the Internet and current literature regarding the physical corner and returning to sport. The moral of the story is that we want the athletes to return back with excellent levels of strength and control through all planes of motion and at all different velocities. I will only touch on one physical piece in this blog post and that is RTS testing. I see time and time again that practitioners are using testing such as hamstring curl, leg press, and knee extension to get objective statuses of strength. But is sport only played with concentric contractions? HELL NO. We need to test our athletes with concentric, isometric, and eccentric positions. Even a single leg hop test doesn’t paint the best picture because athletes absorb forces differently which can present as being symmetrical when they are not (3).  We have to look at the bigger picture here with testing and ask ourselves the question, “What will this athlete be going through in this sport?” The answer surely is not a seated knee extension in a controlled setting. Sport is chaotic. And portions of our testing need to mimic these demands as well. Some of these tests also need to be done while fatigued because this can paint a different picture. One thing for sure, there is always an element of chaos. 


One large gap in the current practice of ACL rehabilitation surrounds the other 3 corners of the game. How are we evaluating whether or not the athlete is prepared in these domains? In this blog, I will touch on some of my thoughts surrounding these other three corners. 


Technical:


We often hear the saying, “It will be just like riding a bike when you return back to sport.” But is it? For roughly 6-7 months of this rehab, our fundamental movements are flawed. We are often using compensatory movements in the guarding process that occurs, especially in the first three months when we are navigating swelling, range of motion, etc. The technical aspect of rehabilitation can be one of the happiest moments for the athlete because they are back doing something they love, like playing with the ball. In this technical phase, we often have to stage the exercises to ensure that the athlete is staying within their limits. For example, are we going to put the athlete into an exercise requiring change of direction and passing if we haven’t progressed to eccentric decelerations in the gym? Probably not, but many do. Our process in the gym and field need to guide the process in returning the athlete to technical pieces on the ball. Our objective testing protocols allow us to see some deficiencies throughout the rehab process that can support these decisions. Through out this technical transition, the athlete will also be going through psychological feelings that may impact how they enter this transition phase. We need to listen to the athlete and the athlete needs to communicate with us. So let’s explore that corner a little further. 


Psychological:


This corner of a player model is critical in the return to sport phase of rehab. Psychologically this player likely had many challenging moments through their rehab and it’s critical that they are feeling confident in their knee when they return to training and ultimately their sport. Carson and Polmon wrote a brilliant case study looking at the psychological aspect of ACL Rehabilitations and found a few important concepts (1). It is critical that the athlete accepts this injury as quick as they possibly can. It is through this acceptance phase that they can start to focus on recovery and become actively involved in the rehab process (1). 


The post surgery phase is the next challenge of these rehabs. There is a mix of emotions in this phase. The athlete is usually very happy that the surgery has gone well and there was no complications but on the flip side, they struggle with the fact that they are heavily limited in what they can do. Often times they can be quite worried about the pain they are feeling in the knee but with the right team behind them, we can guide them through what is normal pain and what may not be normal. 


After the post surgery phase, the athlete can start to see progress being made which is a big psychological win. One of the toughest challenges for these athletes as they approach the RTS phase is that they may feel ready. They are pleased with the progress they have made and everything can feel extremely good. The challenge is keeping them back when the literature points to using objective data and a steady chunk of time to clear the athlete. It is pushing towards the 1 year mark in amateur athletes. I always call this phase “the light at the end of tunnel,” because we are still in the tunnel. The work in the gym is a lifelong commitment to that athlete as long as they are in sport. We can see the end but we are not quite there. 


I can’t emphasize enough the importance of the athlete having confidence in their knee joint when they return to sport. Of course there will be some aspect of hesitation but this often diminishes after the first tackle, the first game, and the first couple weeks back following the rehab. Confidence remains the theme here. Our job is to pull the athlete out of the injury and create a sense of chaos in their end stage rehab so that when it comes time for sport, it’s not a new challenge for that athlete. This includes incorporating enough high speed running, change of direction progressions, and agility progressions. They have already gone to war with their new knee, in this new phase. The next corner highlights how the athlete fits in within the tactical model of the coach or team. 


Tactical:


Now the tactical aspect of RTS rehab for ACL’s is not very well researched in the current body of literature. The tactical model simply refers to the coaches team style, formations, or identify that the coach tends to implement. For example, are we playing a 4-2-3-1 with a high press out of possession? These are the things we need to start thinking about when that athlete is nearing the end of their rehab. Where does that athlete fit in, within that picture. Position plays an important role because the demands of each position are different. If you haven’t dove into that aspect yet I highly recommend jumping into some of Tim Gabbet’s work which looks at GPS data across many different leagues and levels. Have we worked up the appropriate tangible data metrics such has high speed running so that the athlete can successfully make runs forward as a modern day fullback? If they are a central midfielder, we tend to have more changes of direction so have we worked up to these values? If they are a GK, have we spent time working in the frontal plane or trying to catch a ball with perturbation and dealing with that subsequent landing? These are all things we need to start to think about with our ACL rehabs. 


There are so many amazing resources out there for coaches who are trying to learn more about ACLs. I think a great place to start is some of the work by Enda King, Matt Taebner, Matt Jordan, etc. They are all brilliant coaches who have really created some valuable resources in terms of ACL rehabs. Simply put, I don’t think we put enough emphasis on all four corners in the ACL RTS model. I believe we are doing youth athletes an injustice by giving them a booklet with exercises and timelines and expect them to be ready for performance at the end of the 1 year mark. If we aren’t measuring as we go, we are just guessing. I am so passionate about these injuries and want to see an accessible model available for everything so they can be guided through the process and not leave it up to chance if they will become a statistic with a re-tear. Let’s be better for these athletes. 


(1) Carson, Fraser, and Remco CJ Polman. "ACL injury rehabilitation: A psychological case study of a professional rugby union player." Journal of Clinical Sport Psychology 2.1 (2008): 71-90.

(2) Ellison, A. E.; Berg, E. E. (1985). "Embryology, anatomy, and function of the anterior cruciate ligament". The Orthopedic Clinics of North America. 16 (1): 3–14. PMID 3969275

(3) Kotsifaki A, Korakakis V, Whiteley R, et al Measuring only hop distance during single leg hop testing is insufficient to detect deficits in knee function after ACL reconstruction: a systematic review and meta-analysis British Journal of Sports Medicine Published Online First: 29 May 2019. doi: 10.1136/bjsports-2018-099918