ACL Reconstruction in Singapore: What To Expect On Your Road To Recovery

By Chun Kiat

An ACL injury involves a tear or sprain of the anterior cruciate ligament, one of the strong bands of tissue that connect the thigh bone to the shinbone. Recovery from an ACL injury typically involves a combination of rest, physical therapy, and sometimes surgery, depending on the severity of the tear. Physiotherapy focuses on strengthening the muscles around the knee to provide better stability and support. A well-structured rehabilitation program is crucial to help patients regain full range of motion and return to their previous level of activity. For those who require surgery, the procedure usually involves reconstructing the torn ligament using a graft, which can be sourced from the patient's own body or from a donor. Post-surgery, a dedicated rehabilitation plan is essential to ensure a successful recovery and to minimise the risk of re-injury.

Preventative measures can also be taken to reduce the risk of an ACL injury. These include proper training techniques, strength training, flexibility exercises, and the use of appropriate footwear. Athletes are encouraged to develop good landing techniques and to focus on exercises that improve balance and coordination.

Overall, while an ACL injury can be a significant setback, with the right treatment and rehabilitation, many individuals are able to return to their favourite sports and activities, often stronger and more resilient than before.

The Causes of Injuries

In Singapore, ACL injuries typically happen during sports and fitness activities that place stress on the knee, including:

• Sudden Slowing Down and Changing Direction:

  Quick changes in movement can strain the ACL.

• Pivoting with Your Foot Firmly Planted:

  Twisting motions while the foot is fixed can cause the ligament to tear.

• Landing Awkwardly from a Jump:

  Incorrect landing techniques can put excessive force on the knee.

• Stopping Suddenly:

  Abrupt stops can strain the knee joint.

• Receiving a Direct Blow to the Knee or Having a Collision:

  Impacts, such as a football tackle, can damage the ACL.

The Symptoms

An ACL injury typically presents with several distinct symptoms, including:

A Loud Pop or a “Popping” Sensation in the Knee:
Many individuals report hearing or feeling a pop at the time of the injury.

Severe Pain and Inability to Continue Activity:
The pain can be intense and may prevent further movement or activity immediately after the injury.

Rapid Swelling:
Swelling around the knee occurs quickly, often within a few hours.

Loss of Range of Motion:
The knee may become stiff, and bending or straightening it fully may be difficult.

A Feeling of Instability or Giving Way with Weight Bearing:
The knee may feel unstable or the sensation that the knee is giving way when attempting to stand or walk.

These symptoms indicate a possible ACL injury and warrant immediate medical evaluation for proper diagnosis and treatment. Ignoring such symptoms could lead to further complications, potentially exacerbating the injury and prolonging recovery time. It's crucial to consult with a healthcare professional who can recommend imaging tests, such as an MRI, to confirm the diagnosis and discuss the best course of action. Treatment options may range from physical therapy and rehabilitation exercises to surgical intervention, depending on the severity of the injury. Early and appropriate management can significantly improve outcomes, helping individuals return to their normal activities and prevent future injuries.

Myths/Facts

The ACL tear is a very common sports injury, but it can happen to both athletes and non athletes as well. If you tear your ACL it's not always necessary to go straight to surgery.

Myth 1: Only Athletes get ACL Tears 

Both average people and professional athletes can suffer from an ACL tear. A simple misalignment of the knee can cause a pop or snap sound, often accompanied by intense pain, bringing an abrupt halt to your favourite sports activities—at least temporarily.

Myth 2: These Injuries are only caused by blunt-force trauma 

All it takes is a turn in the wrong direction when your foot lands to cause an ACL injury. This small misstep can lead to a cascade of consequences, from swelling and intense pain to a long and arduous recovery process. Athletes, in particular, are well-acquainted with the risks associated with such injuries. However, it's not just elite sportspeople who suffer; anyone can be vulnerable in everyday activities.

Myth 3: An ACL tear will end your sports career 

An athlete's career may not always be ruined by an ACL tear, but it does happen occasionally. In other cases, it might keep you off the field for a while and force you to prioritise your own health, but you could still fully recover and make a full recovery before returning stronger than ever. There's no way to be certain because everyone is unique. A rehabilitation programme that is adhered to will guarantee the best possible outcome for your knee.

Myth 4: Surgery is the only option for an ACL tear

A full ACL tear often requires surgery, but minor tears can be treated non-surgically with RICE (rest, ice, compression, elevation) and physiotherapy. Physiotherapy helps strengthen leg muscles, stabilising the knee and compensating for the torn ACL. Treatment choice depends on tear severity and individual factors.

Myth 5: The knee has to be cut wide open 

Arthroscopy, a minimally invasive technique, is commonly used to reconstruct a torn ACL. This method involves making small incisions and using a camera to guide the surgical instruments. The benefits of arthroscopy include less scarring, reduced blood loss, and shorter recovery time compared to traditional open surgery. Because the knee isn't cut wide open, healing tends to be faster.

Additionally, non-invasive methods such as physiotherapy and muscle strengthening can aid in recovery. Physiotherapy focuses on exercises to strengthen the muscles around the knee, enhancing stability and function. This approach can help the knee heal and become stronger, potentially allowing individuals to return to their activities more quickly and safely.

Myth 6: Rehabilitation takes a long time 

Everyone is different and some people have underlying health conditions, which may mean longer healing times as well as healing can be dependent on how often one does their exercises. Ligaments, having fewer blood vessels than bones or muscles, generally heal more slowly. This reduced blood supply means less blood and nutrients are available to support tissue healing.

Myth 7: You can never run again 

The results of ACL surgery and rehabilitation can vary greatly. Some people can return to their previous level of activity by regaining strength, stability, and function in their knees through careful adherence to post-operative rehabilitation protocols. These people can confidently resume their daily activities and sports with little long-term effects.

Others, though, might still have problems even after surgery and rehabilitation. The outcome can be influenced by various factors, including the degree of the tear, related injuries, personal healing reactions, and compliance with rehabilitation regimens. Some people might discover that their knee never fully regains its strength or stability, or they might deal with chronic pain that limits their daily activities.

Do’s and Don’ts

With ACL injuries becoming more and more common within the world of sport, it is important to understand one's injury in order to maximise the effectiveness of rehabilitation. There are several Do’s and Don’ts that can be followed for effective ACL rehab.

The Do’s

• Listen To The Knee

  If you experience pain and swelling after doing any exercises or activity it is a sign to slow down and take a step back, especially regarding any impact loading activities or exercises that are being done. Ignoring this feedback can slow down efforts to improve range of movement and quadriceps activation in the early stages of ACL rehab and can actually cause it to take longer to return to sports. 

• Use The Leg Extension Machine

  The leg extension machine can be a valuable tool in ACL rehab, but it should be introduced gradually and under professional guidance to ensure it supports your recovery without compromising the healing process of the ACL graft following a procedure.

• Don't Start Running Immediately

  While running is an important goal, it should not be attempted immediately. Patience and adherence to a structured rehabilitation program are crucial to ensure proper healing, reduce the risk of complications, and promote a successful return to physical activities, including running, in due time.

• Start With Low Impact Exercises

  Starting with low-impact exercises is indeed a recommended approach to gradually regain strength, mobility, and stability in the knee joint.

The Don’ts

• Rush Into Surgery

  The decision to undergo ACL surgery should be carefully considered. While surgery may be necessary for some individuals, others may find that conservative treatments can effectively manage their ACL injury. Each case is unique, and the treatment plan should be personalised to achieve the best possible outcome for the patient.

• Wait For 3 Months Then Return To Sports

  It is essential to follow the guidance of your healthcare team and allow sufficient time for proper rehabilitation. Rushing the process can lead to setbacks and compromise your ability to perform at your best in the long term.

• Skip Strength and Agility Training

  This can compromise recovery, increase the risk of re-injury, and hinder the ability to return to sports or activities at pre-injury levels. Incorporating these components into a structured rehabilitation program is essential for achieving optimal outcomes and long-term joint health.

• Go Straight Back Into Full Training

  A gradual and structured approach to returning to full training following an ACL injury is essential for optimal recovery and reducing the risk of complications. Tailor a rehabilitation program to your specific needs and ensure a safe and successful return to sports or physical activities.

Reduce Risk of Developing Knee Pain

To reduce knee injury, especially following an ACL injury, the P.O.L.I.C.E. protocol is highly effective.

Protection involves avoiding activities that may worsen the injury and using supports like braces.

Optimal Loading promotes gentle, controlled movements to encourage healing without overloading the knee. 

Ice should be applied regularly to reduce swelling and pain. 

Compression with bandages or wraps helps control swelling and provides support. 

Elevation of the knee above heart level reduces fluid accumulation and swelling. Implementing these steps promptly can significantly aid in recovery and prevent further damage.

How Milestone Physiotherapy Can Assist

In Singapore, our physiotherapists from Milestone Physiotherapy can assist with both pre-operative and post-operative rehabilitation. We recommend that patients start with physiotherapy before surgery to strengthen the quads and other muscles, providing better control and preparing the body for surgery. Pre-operative rehabilitation allows physios to understand patients' normal knee size, current conditions, hobbies, goals, and capabilities.

At a Milestone Physiotherapy near you, we are guided by the Melbourne protocol for treating ACL injuries. This protocol is structured into several stages, each serving as a threshold that patients must overcome to advance in their rehabilitation process. Here’s a detailed look at the stages:

Stage 1: Initial Recovery

• Goal: Reduce swelling and achieve knee bend of approximately 180 degrees.

• Methods: POLICE principle (Protection, Optimal Loading, Ice, Compression, Elevation) is applied to control inflammation and promote early movement. Gentle exercises are introduced to maintain joint flexibility and muscle activation without stressing the ACL.

Stage 2: Functional Strength and Stability

• Goal: Perform a single-legged squat.

• Methods: Focus on building strength in the quadriceps, hamstrings, and surrounding muscles. Controlled exercises and resistance training are implemented to enhance knee stability and overall leg strength. Balance and proprioception exercises are also introduced to improve coordination and knee control.

Stage 3: Advanced Strengthening and Functional Training

• Goal: Achieve higher levels of functional strength and prepare for return to activity.

• Methods: Progressively challenging exercises that mimic sports or daily activities are added. Plyometric exercises, agility drills, and sport-specific training are incorporated to prepare the knee for dynamic movements.

Stage 4: Return to Activity

• Goal: Safely resume normal activities, including sports.

• Methods: Gradual return to sports and activities with close monitoring to ensure proper technique and prevent re-injury. Ongoing strength and conditioning programs are maintained to support long-term knee health.

Additional Recovery Methods

• Sports Massage: Helps to alleviate muscle tightness and improve blood flow to the injured area.

• Dry Needling: Targets muscle tension and trigger points around the knee, excluding the joint itself, to reduce pain and improve function.

• Active Movement: Encouraged throughout the recovery process to facilitate fluid drainage, reduce swelling, and promote tissue healing.

By adhering to the Melbourne protocol and incorporating comprehensive recovery methods, Milestone Physiotherapy ensures a holistic approach to ACL injury rehabilitation, tailored to the individual needs and goals of each patient. Regular progress evaluations and adjustments to the rehabilitation program ensure that patients remain on track and motivated. Additionally, we emphasise the importance of patient education, empowering individuals with the knowledge and skills to manage their condition and prevent future injuries. Here, we not only aid in physical healing but also support patients in regaining confidence and achieving their full potential.

Optimising Athletic Potential: Integrating Physiotherapy and Sports Medicine for Performance Enhancement

Chun Kiat Goh

In the competitive world of sports and athletics, the relentless pursuit of excellence is paramount. Athletes are continuously pushing their boundaries, seeking every advantage to elevate their performance and achieve their aspirations. Among the array of methodologies available, the integration of physiotherapy, sports medicine, and orthopaedic surgery stands out as a cornerstone for optimising athletic prowess.

Physiotherapy and sports medicine are two intertwined disciplines dedicated to injury prevention, rehabilitation, and performance enhancement. By seamlessly integrating their expertise with that of orthopaedic surgeons, practitioners can comprehensively address the intricate needs of athletes, guiding them towards peak performance while mitigating the risk of injuries. This article explores the synergistic relationship between physiotherapy, sports medicine, and orthopaedic surgery, emphasizing their pivotal roles in maximising athletic potential.

Understanding Physiotherapy

Physiotherapy, also referred to as physical therapy, is a specialised healthcare profession focused on restoring movement and function in individuals affected by injury, illness, or disability. Physiotherapists employ various techniques such as manual therapy, exercise prescription, and therapeutic modalities to address musculoskeletal issues and facilitate recovery.

In the context of athletic performance, physiotherapy plays a pivotal role in both injury prevention and rehabilitation. Through targeted exercises, corrective techniques, and biomechanical assessments, physiotherapists assist athletes in optimizing their movement patterns, enhancing joint stability, and minimising the risk of overuse injuries.

Physiotherapy interventions are tailored to meet the unique needs and goals of each athlete, whether it involves managing acute injuries, addressing chronic conditions, or optimizing overall performance. By fostering resilience, mobility, and functional capacity, physiotherapy empowers athletes to perform at their peak while minimising the likelihood of setbacks.

Exploring Sports Medicine

Sports medicine encompasses a multidisciplinary approach to the prevention, diagnosis, treatment, and rehabilitation of sports-related injuries and conditions. Professionals in this field, including physicians, physiotherapists, athletic trainers, exercise physiologists, and orthopaedic surgeons, collaborate to deliver comprehensive care to athletes of all levels.

A primary objective of sports medicine is to optimise athletic performance through a combination of medical interventions, tailored exercise programs, and performance enhancement strategies. This may include biomechanical assessments, personalized strength and conditioning regimens, nutritional guidance, and psychological support.

In addition to performance enhancement, sports medicine professionals play a crucial role in injury management and rehabilitation. Whether treating acute injuries such as sprains and strains or addressing chronic conditions like tendinopathies and stress fractures, these practitioners utilise evidence-based interventions to facilitate recovery and expedite return to play.

Integrating Physiotherapy, Sports Medicine, and Orthopaedic Surgery

The integration of physiotherapy, sports medicine, and orthopaedic surgeons represents a holistic approach to maximising athletic potential. By harnessing the collective expertise of these disciplines, practitioners can effectively address the multifaceted needs of athletes, encompassing injury prevention, rehabilitation, and performance optimization.

A fundamental aspect of this integration involves comprehensive biomechanical analysis and movement assessment. Physiotherapists, sports medicine professionals, and orthopaedic surgeons collaborate to identify movement imbalances, asymmetries, and dysfunctional patterns that may predispose athletes to injuries or hinder performance. Through targeted interventions such as corrective exercises, manual therapy techniques, and surgical interventions when necessary, athletes can optimize their movement efficiency and mitigate the risk of injuries.

Another critical component is the development of individualized strength and conditioning programs. Collaborating closely, physiotherapists, sports medicine professionals, and orthopaedic surgeons design tailored exercise protocols that align with specific performance goals, whether it's enhancing strength, power, agility, or endurance. These programs are informed by the athlete's injury history, biomechanics, and sport-specific demands, ensuring optimal training adaptations while minimizing the risk of overexertion or injury.

Nutrition plays a vital role in the integration of physiotherapy, sports medicine, and orthopaedic surgery as well. Professionals collaborate with registered dietitians to devise personalized nutrition plans that support optimal performance, expedite recovery, and promote overall well-being. By optimizing nutrient intake, hydration, and supplementation, athletes can effectively fuel their bodies and maximize their training adaptations.

Rehabilitation represents yet another area where the synergy between these disciplines shines. Following an injury or surgical intervention, athletes undergo comprehensive rehabilitation programs aimed at restoring function, mobility, and strength. Physiotherapists, sports medicine professionals, and orthopaedic surgeons collaborate closely to monitor the athlete's progress, adjusting the rehabilitation plan as needed to ensure a safe and successful return to sport.

Real-time Statistics

Recent studies highlight the effectiveness of integrated physiotherapy, sports medicine, and orthopaedic surgery interventions in optimising athletic performance and reducing the incidence of recurrent injuries. According to research published in the Journal of Orthopaedic & Sports Physical Therapy, athletes who undergo integrated care experience faster recovery times and lower rates of recurrent injuries compared to those receiving conventional treatments alone.

Moreover, data from the American Physical Therapy Association underscores the positive impact of structured strength and conditioning programmes supervised by multidisciplinary teams on various performance metrics such as speed, agility, and power.

Conclusion

In conclusion, the integration of physiotherapy, sports medicine, and orthopaedic surgery represents a synergistic approach to maximising athletic potential. By leveraging their collective expertise in injury prevention, rehabilitation, and performance enhancement, practitioners can effectively support athletes in their pursuit of excellence while safeguarding their long-term health and well-being.

Athletes, coaches, trainers, and healthcare providers alike stand to benefit from embracing this multidisciplinary approach, harnessing the synergies between physiotherapy, sports medicine, and orthopaedic surgery to optimise athletic performance and promote lifelong participation in sports and physical activity.

Anterior Cruciate Ligament Injuries In Football

By Chun Kiat

Football, a sport celebrated for its exhilarating moments, strategic gameplay, and passionate fan base, also carries the unfortunate burden of a common and often debilitating injury: the Anterior Cruciate Ligament (ACL) injury. This injury has plagued players at various levels, from grassroots to professional.

The ACL Tear

The majority of ACL tears result from movements without direct contact, like a sudden twist where the player lacks sufficient muscle strength to counteract the twisting. Whether a player steps into a depression in the ground or lands in an awkward manner, the knee can shift, leading to an ACL tear.

During such incidents, players frequently describe hearing or feeling a distinct "pop”. In the hours following an ACL tear, swelling and blood accumulation in the knee are common. Many players also report a sensation of instability or "wobbliness" in the knee after experiencing an ACL tear.

Why Are ACL Injuries So Common In Football?

Football requires movement patterns that exert regular strain on the knee. The ACL is especially vulnerable in soccer due to two primary factors:

1. Swift changes in direction — Football involves rapid directional changes, rotational actions, awkward landings, repetitive motions, and pivots. These movements, combined with playing on artificial turf, impose significant stress on the knee. The abrupt force and velocity, surpassing the knee's accustomed limits, may result in an ACL injury or tear.

2. Player contact — In instances of player collisions, external force or impacts to the knee can be a catalyst for ACL injuries.

How Does It Happen?

According to a recent study published in 2020 where 134 ACL injuries in elite football were examined. They found:

• 44% of ACL injuries were non-contact

• 44% of ACL injuries were indirect

• 12% of ACL injuries involved contact to the knee

How Long Does It Take To Recover?

The typical recommendation for a comeback to the field after an ACL tear is a recovery period of approximately nine months. For example, Virgil van Dijk, from Liverpool FC, made his return after 9 months.  Still, some players take 12-18 months to get back to full play as the severity of the injury varies.

Nevertheless, it is crucial to carefully weigh the timing of your return. The decision-making process is intricate and requires the involvement of various parties, and it also depends on your level of competition.

How Many Footballers Return To Football Post-Injury?

What are the odds of your comeback? A study published in the American Journal of Sports Medicine in 2012 delved into the speed of recovery for football players post-ACL reconstruction. The study discovered that 72% of football players successfully resumed playing after undergoing ACL surgery.

 Intriguingly, the research also revealed the following:

• Among the returning players, the average time for their return was 12.2 months post-surgery.

• Impressively, 85% of those who made a comeback eventually reached or surpassed their previous level of football performance.

With that being said, some of you may be familiar with these particular real life examples:

Alan Shearer

Newcastle’s legend, Alan Shearer, ruptured his ACL in a game against Leeds United on Boxing Day 1992 while playing for Blackburn Rovers. The injury happened in the first half of the game, without his knowledge. Nonetheless, he scored 2 goals for his team and they won 3-1 in that game. 

After recovering from his injury, the Newcastle legend returned in the 93-94 season to score 31 goals in 40 games. He then continued to smash other records over the years.

Shearer dedicates his post injury success to this quote, “Be patient, don’t cut corners, and do everything the physio tells you.” If he could do it in the 90s, surely you can in today's day and age!

Ruud van Nistelrooy 

Dutch forward Ruud van Nistelrooy was on the verge of becoming Manchester United's most expensive signing in 2000 when a setback occurred during his medical  due to an injury sustained while playing for PSV Eindhoven. Subsequently, he ruptured his ACL during a training session.

After a challenging nine-month recovery period, he successfully secured his move a year later. Van Nistelrooy went on to score 150 goals in 219 games for Manchester United. During his tenure, the club secured the Premier League, League Cup, and FA Cup trophies. Additionally, he continued to shine by winning La Liga twice with Real Madrid.

Zlatan Ibrahimovic

In April 2017, the then 35-year-old Manchester United forward Zlatan Ibrahimovic experienced cruciate knee ligament damage in the last minute of normal time during a Europa League quarter-final second-leg triumph against Anderlecht. Initially expected to be sidelined for a full year, there were concerns that this injury might mark the end of his career. However, he made a remarkable comeback after just seven months.

In his characteristic style, Zlatan remarked, "Lions don't recover like humans." Years later, at the age of 39, he continued to excel. In the 19-20 season, he scored 11 goals in 20 matches for AC Milan.

Xavi

Xavi stands as one of Barcelona's most significant players in the club's history, holding the record for the highest number of appearances.

In December 2005, a critical ACL injury required surgery, posing the risk of exclusion from the Spain squad for the upcoming World Cup in Germany. Remarkably, after only a five-month hiatus, he made a swift return, contributing to Barcelona's La Liga title victory and participating in the World Cup with Spain that summer.

His subsequent career was illustrious, accumulating five additional La Liga titles, four Champions League trophies, two European Championships, and one World Cup.

Francesco Totti

As the 2007/08 season was coming to an end, Roma's iconic captain Francesco Totti faced a devastating setback when he sustained a season-ending injury, tearing his ACL during a match against Livorno.

The AS Roma legend only spent 4(!) months on the sidelines because of the injury he sustained back in 2008. He went on to play for nearly a decade and eventually retired at the age of 40.

What Psychological Challenges Do Football Players Face During The Recovery Process From An ACL Injury?

Recovering from an ACL injury in football involves not only physical rehabilitation but also significant psychological challenges for players. Here are some of the common psychological hurdles that footballers may encounter during the recovery process:

• Fear of Reinjury: 

• Players often grapple with a fear of reinjury, especially when returning to high-impact activities. The mental hurdle of trusting the knee again can be a significant challenge.

• Frustration and Impatience:

• The lengthy rehabilitation process can lead to frustration and impatience. Players may feel a sense of restlessness as they navigate through the slow and gradual stages of recovery.

• Loss of Confidence:

• Suffering an ACL injury can shake a player's confidence in their physical abilities. Regaining the mental strength and self-assurance to perform at pre-injury levels can be a psychological struggle.

Addressing these psychological challenges requires a comprehensive approach, including mental health support, communication with teammates and coaches, and setting realistic expectations for the recovery journey. Mental resilience is a crucial aspect of overcoming an ACL injury and returning to peak performance on the football field. Physiotherapists also play a pivotal role in this by offering emotional support, motivation, and encouragement. This holistic approach helps players maintain a positive mindset during recovery. 

In conclusion, while an ACL injury may initially feel like a setback, it's important to recognize that it is by no means the end of the world for athletes or individuals passionate about staying active. The journey to recovery may be challenging, but embracing rehabilitation with dedication and a positive mindset can lead to not only a full recovery but also improved strength and resilience. 

With that being said, the treatment approach for each individual varies from person to person. Some require surgery while some might not, depending on their lifestyle. While surgery may offer a more direct route to stabilising the knee and potentially hastening the recovery process, it is not the only solution. Non-surgical methods, including physical therapy, targeted exercises, and lifestyle adjustments, can lead positive outcomes for many individuals, particularly those with partial tears or less active lifestyles.

What are the risks of returning to football too soon?

Returning to football too soon after an ACL injury poses various risks. The ACL, vital for knee stability, requires time to heal properly. Premature return increases the risk of incomplete recovery, re-injury, and compromised stability, heightening susceptibility to further injuries. Inadequate healing may lead to cartilage damage and long-term consequences.

Comprehensive rehabilitation, guided by healthcare professionals and adherence to recommended timelines, is crucial for proper healing and the development of strength and stability needed for a safe return to football.

Andrew’s Thoughts & Reflections On Anterior Cruciate Ligament (ACL) Injuries And The Physiotherapy Process

By Andrew

Over the years, I have been part of the decision-making process for many patients after their ACL injury. It is very rewarding to be part of a patient's return to sport or activities of daily living pain free. My goal as a physiotherapist is to always to get the best possible outcome for all patients.

Surgery is not for everybody, and rehab is not for everybody either. Not everybody wants or should expect to return to sport post-ACL reconstruction surgery. There are many factors which will affect the decision to go for surgery or choose standard rehab.

I have recently managed a high performing football player, Charlie, who will return to play in the next few weeks. Charlie's injury happened while playing a football match in Singapore. While pivoting to shoot, and his knee gave way into a bend and inward twist, a classic mechanism of ACL injuries. For the reconstruction, Charlie decided to use a hamstring autograft approach. Charlie's most recent physiotherapy session can be seen in the clip below.

Our Principal Physiotherapist Andrew Storan takes our patient through a workout after his anterior cruciate ligament reconstruction surgery, combining strength, agility, balance, and power training to promote a successful return-to-sports.

Here is a list of the top ten questions that I have been asked over my years of work about ACL reconstruction surgery and the subsequent physiotherapy process.

• Q: Who is suitable for ACL reconstruction?

  A: Simply put, anybody suffering with instability post-ACL injury. Sometimes the instability can be present with a partial tear but more likely to be present with a full tear of the ACL.

  There are other factors like age and the presence of degenerative cartilage which are predictors of outcome.

  A detailed discussion is required to determine suitability and is done with advice of physio and orthopaedic surgeon.

• Q: How do you test for instability?

  A: Scans, being static in nature, will never be able to fully reveal whether a patient is unstable. There are clinical tests that can be done. These tests are usually done during rehabilitation. If the patient shows instability signs during rehab testing then that can be an indication for surgery.

• Q: Are there any alternatives to surgery?

  A: There is a new approach the “Cross Bracing Protocol” recently published by researchers from The University of Melbourne (Fibay et al., 2023).

  This approach restricts range for a period of 12 weeks and aims to allow the ACL to heal. There are also case studies where patients have made a recovery.

  This is all very new at the moment and the jury is out as to whether this will be a viable option with excellent long-term results. More research is required.

• Q: How long is rehabilitation post-surgery?

  A: 9 to 12 months is required to make a full recovery back to sports. Rehabilitation without surgery will usually take place over 4 to 6 months. 

• Q: Is prehabilitation required before surgery?

  A: Prehabilitation (“prehab”) is certainly valuable. Patients who have gone through a structured physiotherapy programme before their surgery have been seen to have better outcomes post-surgery.

• Q: Can I have the surgery if I don't have time for the rehabilitation afterwards?

  A: I would strongly discourage surgery for a patient who cannot commit the time to rehabilitate and recovery. Patients who travel frequently for work should also consider this, adequate rest and time spent in the gym is required to make a full recovery.

• Q: Can I return to my previous level of competitive sport if I have surgery?

  A: ~65% return to their previous level of sport post op. There are a lot of factors which predict whether you will make it back to previous level like age, secondary knee damage, attitude to rehabilitation, stress, and overall general health. 

• Q: How long will it take me to return to my desk-based job?

  A: Most people are on crutches for a few weeks post-surgery and will be able to return to work after a few weeks all going well.

• Q: Is there a chance I can tear the ACL a second time?

  A:  Studies have shown that there is a 6% chance of re-tearing the ACL after surgery. 

• Q: Which graft is the best? Hamstring tendon, quadriceps tendon or allograft?

  A: There are pros and cons with each graft option.

  Hamstring grafts have been shown to reduce anterior knee pain and knee stiffness but can cause reduced hamstring strength post-surgery.

  Quadriceps tendon has limited research and can cause reduced quadriceps strength post-surgery.

  The allograft option is very popular as it results in less knee pain and does not impact the hamstring strength. It can however be a weaker graft overall.

  The decision to choose a graft is made with the surgeon and surgeons will have their own preferences depending on the patient's injury and history. 

• Q: Do I need access to a gym to complete my rehabilitation?

  A: It will be very helpful to have access to a gym but you can complete a home exercise program without ever leaving the house.

  I would always recommend patients signing up for  gym 3 months post-surgery. I would also recommend patients borrowing or renting a static bike for home use if space allows.