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

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.