Time to return to sports after ACL reconstruction
Most of the players undergoing anterior cruciate ligament (ACL) reconstruction have a common question in mind. When can they play again?? Various factors are important for coming to that decision. And the decision is not based only on surgeon; but player, physio and team management, all plays a crucial role. Some of the points worth considering are as follows.
1. Time after ACL reconstruction
It can be as little as 6 months to as long as 18 months depending on overall recovery and regaining the pre-injury level fitness. Certain players who are dedicated to the rehab program and are at low risk of suffering from ACL injury again; can go back early to sports. Players who have high potential of damaging their ACL due to their inherent design, methodology of play etc are advised to go back to active sports little late. Also players who cannot dedicate themselves to active rehabilitation fully should not expect to return to active sports early.
2. The quality and dedication with which player undergoes Post ACL rehab
ACL reconstructive surgery is a team work. Surgery performed is not the end of the problem but rather a new beginning. It is a team work that comprise of player, surgeon, physio and the team management. Player and team management should give enough importance to the time and dedication required for post-ACL rehabilitation before one can go back to active sports. Surgeon and physio should consult each other about various aspects of surgery and the strategy for the rehabilitation program for the player. Though there are more or less fixed rehab protocols by each surgeon; it still requires customization. Lastly, a joint meeting between all the four is crucial before player hits the ground.
3. Motion is foremost
A player has a high tendency to lose full range of movements of the affected knee, after injury and also after ACL reconstruction surgery. After injury, a collection of blood inside the joint followed by rest and brace application leads to stiffness. After surgery, again a surgical insult to the knee combined with rest and brace again; leads to further stiffness. After injury and after surgery, a dedicated rehab program to maintain the range of motion (ROM) is very crucial. A well performed surgery without complete ROM is not good for the knees. Loss of full extension can lead to very high loads on the patella and on the graft leading to early arthritis or a failure. In the same way, loss of flexion leads to unloading of normal stresses to certain areas of the knee, loss of muscle agility and ultimately early degenerative changes. As part of the staged rehab program, 1st phase of protocol based post ACL- rebab program generally covers this.
4. Regaining Strength is important
Building up pre-injury strength of quadriceps, hamstrings and gluteus is very crucial to keep the loads off, on a newly reconstructed anterior cruciate ligament (ACL). Sometimes, it may be important to overbuild the muscles to avoid a fresh injury in a highly susceptible group. As part of the staged rehab program, 2nd phase of protocol based post ACL- rebab program generally covers this.
5. Neuromuscular control on your hip, knee and overall lower limb
A good neuromuscular control doesn’t come with power alone. Muscles, tendons, nerves and other tissues; all need to be trained for a sufficient amount of coordination. The tissues also need to send good proprioceptive feedback back to brain and brain needs to send good muscular control back to the lower limb. Without a complete training of leg-brain-leg cycle, the body will not work as one unit. As part of the staged rehab program, 3rd phase of protocol based post ACL- rebab program generally covers this.
6. Sportsmen Injury Prevention Program (SIPP)
This is the dedicated program that every institute follows in their own way. Such programs are designed to train players’ proprioceptive abilities to its best so as to minimize the risk of re-injury. As part of the staged rehab program, 4th phase of protocol based post ACL- rebab program generally covers this.
7. Psychological training
A player is not fit until he regains his pre-injury psychological fitness. Some has fear of a re-fall, while others may not take their first injury seriously. A strong mental health and understanding of the subject, injury pattern and high-risk factors is important. Generally, this can be achieved thru counseling but sometimes may require a dedicated psychological training.
Deepak Goyal
Consultant Sports Knee Surgeon