ACL rehab – Both sides of the coin
I have been intrigued in ACL rehab since suffering my niche combination of injuries. Although ACL injuries in young athletes are common, I have suffered bilateral ACL ruptures, with one managed conservatively, the other reconstructed.
I recently came across a podcast involving Mick Hughes, where he discusses non-operative ACL rehab, and how for most high level/sporting athletes this option may have been overlooked. Therefore, I believe sharing my story may give some therapists a new found confidence when treating conservatively managed ACL patients.
In 2015 I suffered a left ACL rupture alongside a lateral meniscus tear. I had my ACL reconstruction and lateral Meniscectomy around 6 months later. A typical, protocol driven, 9-month rehab program followed. My right ACL tear came in December 2017, early February ‘18 by the time I was MRI scanned and diagnosed. My surgeon gave me the option of conservative management as I was minimally symptomatic, which I grabbed with both hands as I was mid-season at university.
For my Initial assessment at the local MSK service I was apprehensive, knowing in 2016 I was misdiagnosed, treated by physio, discharged, and it wasn’t until after 3 months of discomfort, and a return to A+E, I was scanned and diagnosed correctly (I believe many patients will feel this apprehensiveness if they have previously had failed management of any injury). I was hoping to return to play as soon as possible, and was anxious, expecting a rehab timeline of months rather than weeks, and the possibility of another failed rehab.
My Physiotherapist was everything I’d hoped for: enthusiastic, goal specific, person centred. I told them my goal was a match in 6-7 weeks’ time, to which they responded “Let’s be honest, you will play in that game, whether I tell you to or not, so let’s focus on that goal and make sure you are ready”. That sentence inspired me, and I had 100% trust and compliance with my therapist thereafter.
We started with the ‘norm’, lots of proprioception work, bosu balls, single leg work, strengthening etc. Although, even after 1.5 years of Bsc Physiotherapy study, the intensity the rehab progressed to went far beyond my expectations.
I now understand the clinical reasoning behind the progressions, loading the joint at low intensity, introducing higher loads, working through different planes, progressing to working under fatigue, and finally into high intensity sport-specific activity. Progressing from deceleration work, to plyometrics with controlled landings, to high intensity cardio work moving straight into controlled plyometric training, then adding in pivoting at high speeds. However, the one thing I remember my therapist repeatedly coming back to was making sure I was solid and controlled through all landings. I believe this did wonders for my confidence and proprioception, as each successful exercise told me my leg was not going to give-way, and it meant I was consciously aware of where my limb was in space throughout rehab. Long story short, I played the full 80 minutes in that game asymptomatically; I believe solely down to my therapist over the course of that 6-7 weeks.
I remember speaking to a consultant whilst on placement about ACL management, he stated he felt non-operative management led to joint laxity and therefore higher chance of OA and less successful outcomes. However, I believe non-operative ACL management is a viable option, both from current evidence (1), and my own personal experience. Though, I do believe conservative management outcomes may be highly variable. Good quality rehab, along with high patient compliance, is needed to achieve the joint strength and stability compensating for the absent ACL. I also understand that some injuries may indeed require surgery, such as my 2016 injury, as I tried and failed with conservative management (although my therapist was not aware of the actual injuries at the time, therefore my rehab was not specific).
For the record, I believe the outcome of my conservatively managed limb has been better than the operatively managed. I am aware of the bias of non-identical injuries etc, but my opinion still stands.
1) Always be honest with your patient, and take a person-centred approach with agreed, specific goals. This will lead to much greater compliance with every patient.
2) Trust your skills! Don’t advocate orthopaedic management, be confident that your clinically reasoned progressions will improve symptoms, without the need for orthopaedic intervention.
3) Push your patients, remember their goal and always work towards, or even go beyond it. This will give them real confidence in using the limb to its full capacity when you are not watching!
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1) van Yperen, D. T.et al (2018). Twenty-Year Follow-up Study Comparing Operative Versus Nonoperative Treatment of Anterior Cruciate Ligament Ruptures in High-Level Athletes. The American Journal of Sports Medicine, 46(5), 1129-1136. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29438635/
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