Management of Anterior Cruciate Ligament

Reconstruction in Athletes
Allison Baker
November 20, 2015
Motor Learning and Neural Control Noah Gentner

Abstract.
An ACL injury is a very common sports-related injury and is becoming more
prevalent amongst athletes worldwide. Although it is important to focus on reducing the
risk of the injury occurrence, it is an injury that can occur with or without opposing
contact, even during low intensity activities. ACL reconstruction surgery is a necessary
intervention to repair a torn ACL and allow athletes to return to sport, however
commitment to recovery afterwards is difficult, yet critical. In order to optimize recovery
and reduce time to return to sport, it is essential for athletes to follow a well-developed
general protocol, with individualized characteristics in order to address all factors that
may influence their recovery success. Although, all patients experience different barriers
to recovery, and protocols should be implemented on an individual basis, the evidence
agrees on a generalized protocol that should be followed to ensure protection of the new
ligament and surgical implications. General protocol guidelines include time-based stages
over 6-9 months, providing patients with goals to reach and new activities to work on as
they progress. Specialized testing is conducted after all protocol stages have been
completed to ensure athletes can safely return to sport.

Introduction.
Sports injuries are common amongst athletes of all ages, types and skill level.
Knee injuries account for approximately 55% of all sports-related injuries amongst
athletes, specifically, the most common is an injury of the anterior cruciate ligament
(ACL) (Midwest Orthopedics at Rush. (2015). ACL injury occurrences have increased in
the past two decades and account for 50% of all knee ligament injuries (Mohammadi et.

al, 2013), and 88% of injuries which require greater than 10 days away from sport
(Labella, Hennrikus & Hewett, 2014). Injury prevalence can be contributed to an increase
percentage in children being enrolled in organized sport, as well as participating in
intensive training at a younger age (Mohammadi et. al, 2013). Prevalence can also be due
to improvements in imaging, which allows for better diagnostic procedures, leading to
more injury reports (Mohammadi et. al, 2013). ACL specific injuries are more common
in females compared to males while playing basketball, soccer and gymnastics (Labella,
Hennrikus & Hewett, 2014). Many injuries are non-contact in nature and result from
improper body position while performing quick, forceful actions (Labella, Hennrikus &
Hewett, 2014). While activities of daily living can be performed with a damaged ACL,
individuals will experience instability of the knee, and possible swelling, pain and
reduced range of motion. In order to return to sport, it is recommended for athletes to
undergo an ACL reconstruction surgery to allow optimal healing and strengthening in
order to regain full capacity while playing their sport of choice. It is important to
correctly diagnose an ACL injury as it can be easily missed or confused with other knee
injuries. Choosing appropriate intervention techniques and following detailed
rehabilitation protocols have been critical in the success of rehabilitation of an ACL
injury and ability to return to sport. Identifying the most effective management procedure
based on the patients specific injury, needs and goals are important to consider when
individualizing a standard rehabilitation protocol.

Mechanism and risks of injury.

The Anterior Cruciate Ligament is one of four ligaments responsible for knee
stabilization, by preventing the tibia from sliding anteriorly relative to the femur
(Hootman, Dick, & Agel 2007). The ACL acts to prevent extensive knee extension,
aggressive valgus and varus movements and tibial rotation, as well as it protects the
meniscus (shock absorber) from tearing during decelerating, pivoting and landing
(Hootman, Dick, & Agel 2007). The mechanism of injury is typically multifactorial,
influenced by both extrinsic and intrinsic factors. Extrinsic factors include physical or
visual perturbations and shoe-surface interaction during activity, while intrinsic factors
include abnormal biomechanical or neuromuscular systems (Labella, Hennrikus &
Hewett, 2014). During sport, a common body position to cause ACL tears involves an
externally rotated hip with knee close to full extension, while foot planted and body
decelerating (Labella, Hennrikus & Hewett, 2014). Slowing down while running to make
a sharp turn is a common time of increased risk of injury. While the center of mass is
away from or behind the base of support of the athlete, the knee can undergo dynamic
knee valgus movement, causing it to collapse quickly, tearing the ACL from its insertion
point, resulting in a loud popping noise. These high-risk body positions and movements
occur frequently during the sport of soccer, classifying it as the sport with the highest
prevalence of ACL injury (Mohammadi et al., 2013). Although athletes involved in
jumping, landing and pivoting sports are always at an increased risk of injury, young
athletes are at the highest risk of injury during major growth spurts; females around age
12-13 and ages 14-15 for males (Labella, Hennrikus & Hewett, 2014). During these
critical periods, the athletes are experiencing rapid increases in weight, height and bone

length, which can commonly interfere with natural biomechanics by reducing the
athletes ability to control their center of mass. The increase in weight can increase forces
through joints, especially the knee, as well as increase in height creates longer levers,
which can cause increased torque in the knee (Labella, Hennrikus & Hewett, 2014).
Higher rates of injury are shown in females compared to males, which can be contributed
by the increased Q angle as well as the lack of testosterone (Labella, Hennrikus &
Hewett, 2014). Testosterone allows for increases in power, strength and coordination,
leading to better neuromuscular control and therefore decreased risk of injury for males
(Labella, Hennrikus & Hewett, 2014). Overall, athletes are at a high risk of ACL injury,
with females dominating in prevalence.

Diagnosis.
It is common for individuals to live with an ACL injury for months or years
before seeking treatment, however for athletes, it is difficult to continue to participate in
sport at full capacity without proper intervention. Post injury, it is common for
individuals to experience symptoms of acute pain, swelling, knee effusion, reduced
motion and difficulty weight bearing, which lead patients to seek further medical
treatment (White, Di Stasi, Smith & Synder-Mackler, 2013). Without treatment these
symptoms can progress into chronic pain, recurrent effusions, sensation of the knee
giving away and a lack of stability while cutting, pivoting, twisting or jumping
(Labella, Hennrikus & Hewett, 2014). To begin the diagnostic process, an MRI will be
conducted on the injured knee to identify any ligament and meniscal tears or cartilage
damage (Labella, Hennrikus & Hewett, 2014). To support the claims of the MRI, it is

important for a medical professional to perform a variety of clinically specialized

physical knee examinations to test for instability. Assessment of injury is critical to
provide reasoning and planning for surgery or other aggressive intervention procedures.
Physical knee examinations include but are not limited to; the Lachman test, anterior
drawer test, pivot test and effusion test.

Interventions/Treatments.
With an obvious MRI abnormality and positive knee tests, it is typically suggested
for patients to undergo an ACL reconstruction surgery to replace the missing ACL. ACL
reconstruction surgery is not necessary to restore ability to complete activities of daily
living after an ACL injury, however it is necessary for competitive athletes who intend to
participate in pivoting sports at pre-injury level. ACL reconstructive surgery can
maximize recovery, stability and functional capacity of the ACL deficient knee and has
proven to have very high success rates (Siegel, Vandenakker-Albanese & Siegel, 2012).
With advances in medical technology, the ACL reconstruction surgical techniques have
developed into a minimally invasive surgery, with reduced soft-tissue disruption and
subsequent postoperative recovery time (Marx, Jones, Angel, Wickiewicz & Warren,
2003). The updated surgery techniques allow for early weight bearing and accelerated
rehabilitation protocols to facilitate the return to higher functional demands and
competitive sport participation (Ardern, Webster, Taylor & Feller, 2011). There are two
approaches to ACL reconstruction, either using semitendinosus and gracilis (STG) tendon
or bone-patellar tendon-bone graft to replace the missing or damaged ligament
(Mohammadi et al., 2013). Based on the results from a randomized trial conducted by

Mohammadi et al., 2013, using the semitendinosus and gracilis graft approach is most
successful with less limitations and possible risks. Surgical outcomes vary based on the
measurement being made. In terms of impairment-based knee functions, there is a
success rate of 90%, and 85% in terms of activity-based functions, with 44% returning to
competitive sport, post ACL reconstruction (Ardern, Webster, Taylor & Feller, 2011).
ACL reconstruction has also been advocated for individuals intending to return to
physically demanding occupations, where reoccurring stability could interfere with their
performance (Marx, Jones, Angel, Wickiewicz & Warren, 2003). Although approximately
90% patients who undergo ACL reconstructive surgery lack impairments in their injured
knee post surgery, only about 50% of patients return to a competitive level of sport
(Ardern, Webster, Taylor & Feller, 2011). This suggests that there are other factors that
contribute to an individual returning to sport. Factors may be psychologically related
such as; fear of re-injury, self-efficacy, confidence and motivation (Marx, Jones, Angel,
Wickiewicz & Warren, 2003), and are important to consider during rehabilitation
processes.

Rehabilitation protocol.
One of the adverse consequences of injuries is that an athlete cannot train fulltime in his or her sport (Wierike, van der Sluis, van den Akker-Scheek, Elferink-Gemser
& Vissche, 2013). To minimize these negative consequences, it is very important to
ensure a successful outcome of the rehabilitation process (Wierike, van der Sluis, van den
Akker-Scheek, Elferink-Gemser & Vissche, 2013). The initial limitation post-surgery is
the outcomes of the reconstruction such as; pain, range of motion, joint laxity and

strength of the new ligament (Mohammadi et al., 2013). Functional-based outcomes are
also very important to measure in order to indicate level of muscle strength, power and
neuromuscular control throughout the duration of the rehabilitation process (Mohammadi
et al., 2013). To ensure optimal recovery, during the first 4-6 weeks postoperatively the
primary focus should be on achieving full range of motion, both in flexion and extension,
through controlled loading and weight bearing, in order to reduce stiffness and scar tissue
build up in the knee, while still protecting the vulnerable graft repair (Albright &
Crepeau, 2011). The use of a locked hinge extension brace has been shown to be helpful
immediately postoperatively to reduce swelling and aiding in achieving full range of
motion, while avoiding active muscle contractions. To maximize flexion goals, patella
mobilization tactics can also be incorporated (Albright & Crepeau, 2011). Full extension,
within 1-2 weeks is typically achieved before extension, up to 4-6 weeks (Albright &
Crepeau, 2011). Range of motion is necessary before progressing onto strength or
functional training portions of rehabilitation. If full range of motion is not achieved by
the maximal timelines it is common for patients to receive physical manipulation while
under anesthesia (Albright & Crepeau, 2011). Proper gait is also a pivotal component
while proceeding to strength training activities. The loss of the quadriceps muscle causes
a misalignment in the tracking on the patella bone over the femur, commonly resulting in
clicking or catching. Bracing or the use of taping techniques can be utilized to push the
patella medially, to ensure proper tracking (Wright et al., 2015). It has been shown that
patients may immediately post-surgery participate in straight-leg quadriceps
strengthening exercises, without creating an increased risk of graft laxity or stretching
(Kruse, Gray & Wright, 2011). Open-chained exercises should be avoided due to

increased graft strain and patella-femoral compression (Ucar, 2014). Closed-chained

exercises including squats and lunges are safe and functionally effective (Ucar, 2014).
Focusing on restoring limb symmetry and improving knee function using sport-related
movements through neuromuscular training may reduce high-risk movement patterns,
preventing second injury occurrence (White, Di Stasi, Smith & Synder-Mackler, 2013).
Adding proprioceptive training involving direct forces while on an unstable surface, such
as a wobble board or trampoline can be useful to simulate perturbations and help prepare
patients to return to sport (Albright & Crepeau, 2011). Rehabilitation milestones are used
to determine healing and strength gain progressions through the use of functional tests,
which can include, hop tests, single leg squat tests, trampoline landing work and figure
eight running (Mohammadi et. al, 2013). A positive correlation exists between the
duration of follow-up time/rehabilitation and higher-return-to-sport-rate, stressing the
importance of specific and thorough rehabilitation procedures (Ardern, Webster, Taylor &
Feller, 2011). Base on a long-term study, patients have similar success outcomes 2-4
years post ACL reconstruction surgery whether the participated in predominantly homebased rehabilitation program in the first 3 months or in a more clinically supervised
program (Grant & Mohtadi, 2010). Based on these results, patients are not required to
participate in supervised physiotherapy, especially athletes, who have training knowledge
and typically possess self-discipline and can follow the detailed rehabilitation protocol.
Although rehab can be self-monitored, seeking professional assistance for time-based
progression checkups is helpful to obtain feedback and correction suggestions. Although
it is commonly suggested that patients are able to return to sport within 6-9 months post
surgery it is important to note that the ACL graft continues to mature for up to a year and

that return to sport decisions should be based on the remaining rehabilitation criteria and
milestone achievements (Albright & Crepeau, 2011).

Return to sport variables.

With only 50% of patients returning to pre-injury level sport, it is necessary to
identify factors that may contribute to the lack of participation. Besides the physical
recovery of the injury, psychosocial aspects of the rehabilitation are of significant value
(Wierike, van der Sluis, van den Akker-Scheek, Elferink-Gemser & Vissche, 2013). Fear
of causing re-injury is a multi-component factor leading to reduce likelihood of return to
play. For athletes returning to sport it is important for them to understand the risks
associated post-surgery to minimize the reoccurrence of another injury. Despite
clearance for return to sport activities after successful rehabilitation, quadriceps strength
discrepancies still exist between the two limbs and movement asymmetries continue to
persist (White, Di Stasi, Smith & Synder-Mackler, 2013) The contralateral limb is at
more risk, 5-24% compared to the operated limb, 4-15% as the reconstruction has created
a new, stronger ligament. (White, Di Stasi, Smith & Synder-Mackler, 2013). After ACL
reconstruction, female athletes are 16 times more likely to sustain a second ACL injury
compared to male athletes (White, Di Stasi, Smith & Synder-Mackler, 2013). Continuous
use of a brace has been showed to be helpful in patients to improve comfort and
confidence levels (Kruse, Gray & Wright, 2011). Other psychological factors including
cognition weaknesses such as; self-efficacy, avoidance coping and rehabilitation
adherence are likely factors to impede successful recovery (Wierike, van der Sluis, van
den Akker-Scheek, Elferink-Gemser & Vissche, 2013). The way a patient perceives their

injury can range from a state of low self-efficacy, to a state of avoidance coping,
involving the inability to consciously remove oneself from threatening environments or
denying or minimizing seriousness of crisis or consequences (Wierike, van der Sluis, van
den Akker-Scheek, Elferink-Gemser & Vissche, 2013). Athletes can be effected by a lack
of confident returning to sport, or a state of over confidence that puts them at higher risk
for re-injury, possibly causing a longer recovery process and increased time to return to
play. Rehabilitation adherence is another factor that typically prolongs a patients
recovery time post-surgery (Wierike, van der Sluis, van den Akker-Scheek, ElferinkGemser & Vissche, 2013), as school, work and other life commitments interfere with the
heavy demand the rehabilitation requires. Fortunately, for athletes, many have a strong
desire to return to sport as well as more free time, that would typically be used for
training, therefore allow for higher commitment to attending/participating in therapy
sessions and checkups as well as dedicating more time at home to rehabilitation
protocols. Regardless of the patients individual intrinsic or extrinsic factors, in order to
experience a quick and successful recovery and return to sport, especially for athletes, it
is important to limit all the negative consequences of the injury by following an
individualized protocol thats is structured based on the recent evidence, to ensure that
athletes can train and play full-time as soon and safely as possible (Wierike, van der
Sluis, van den Akker-Scheek, Elferink-Gemser & Vissche, 2013).

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