Rehabilitation after ACL injury can be a long and winding road and one of the greatest challenges faced by any athlete as well as those involved in the rehabilitation process. Few injuries challenge your rehabilitation skillset like ACL rehabilitation. It requires a strong theoretical knowledge and practical experience to restore homeostasis to the knee and develop a range of physical qualities to target the deficits inflicted by the initial injury and reconstruction. Given the scale of dysfunction to the joint and the neuromuscular system it is often suggested that if you have the skillset to rehabilitate an ACL injury you can successfully rehabilitate almost any injury. Despite the frequency of ACL injury, yet perhaps due to its complexity, there are no widely accepted rehabilitation guidelines for the practitioner to follow. As we rehabilitate over 200 ACL-injured athletes weekly at Aspetar, the goal of this edition of the Aspetar Journal was to share the expertise and experience of our team and of our international colleagues.
It is important in ACL rehabilitation, to quote Steven Covey, to "Begin with the End in Mind". Clarity on what the end of rehabilitation will need to look like, the physical competency that will need to be achieved, and the transition points throughout that journey, will greatly improve athlete compliance and motivation. It will also ensure continuity of care and messaging from all involved in the rehabilitation team and assist in goal setting and programming across each phase of the rehabilitation process.
Once the journey has been mapped out we highlight the best evidence practice guideline to guide your decision-making regarding the modalities and rehabilitation strategies you should incorporate into your rehabilitation based on the current evidence. We outline the testing process that should be carried out throughout the rehabilitation process including return to sport to highlight want the “fully rehabilitated” athlete needs to look like across a range of tests, variables and metrics.
Once the journey and its key landmarks have been discussed we delve into each of the components of rehabilitation, some of the common pitfalls in each component and how best to optimise interventions. This starts with the preoperative phase, optimising neuromuscular function in that early post-operative phase while targeting the entire kinetic chain (specially the foot and ankle) to provide a solid base for the subsequent rehabilitation phases. Concurrently the role of hydrotherapy is explored and its structure outlined to redevelop function while still respecting the recovery process within the knee.
This foundation is built upon with strategies to develop strength, explosiveness and reactive strength and using these qualities during running and change direction mechanics. All of this with the goal to get back onto the field of course to initiate sport training in a structured manner to best prepare the athlete for return to training. This is not to neglect one of the most important aspects of rehabilitating an athlete back to peak performance which is conditioning throughout the rehabilitation process and then tailoring it to be more specific to the demands of their sport in the latter stages of the process.
We finish by highlighting developments in the management of ACL injury and by looking at the rehabilitation process through the most important set of eyes – that of the athlete so we can learn from their insights and experiences. ACL rehabilitation is a constantly evolving process as our research, technology and clinical reasoning develops. We hope that this edition of the Aspetar journal and the expertise and structures shared within it will support you in helping your athlete during what can be one of the most challenging but also rewarding processes for both the athlete and the rehabilitation team alike.
Our ACL rehabilitation has evolved markedly over the last 20 years, and no doubt this progress will continue as medical care and outcomes research evolves. We hope that by sharing our thoughts and current practice protocols we can promote discussion and further collaboration so we can ultimately get closer to our goals of optimising care for this important patient group.
Rod Whiteley PT, PhD
Enda King PT, PhD