Anterior Cruciate Ligament (ACL) – 7 Common Mistakes and Rehabilitation

A tear of the anterior cruciate ligament (ACL) is the most common injury to the knee joint and one of the most common injuries in general. It represents fear and trepidation for recreational athletes, and especially elite athletes, because of the long and complex rehabilitation it requires. Younger individuals with active lifestyles often decide to undergo ACL reconstruction to increase the stability and function of the knee. The need to take rehabilitation extremely seriously is demonstrated by the figures that 65% of individuals who undergo ACL reconstruction return to their previous level of the recreational sporting activity, while only 55% return to a competitive level. In addition, 30% of athletes re-injure their anterior cruciate ligament (ACL) within two years of returning to sport (2).

The human body is designed to move, and it is a fact that anterior cruciate ligament (ACL) injuries are unfortunately part of sports participation, despite the individual being in good physical condition. They cannot be completely avoided. All we can do is reduce the risk of injury. However, when a traumatic anterior cruciate ligament (ACL) injury does occur, at Medicofit clinic, under the supervision of physiotherapists and kinesiologists, we safely guide the athlete through rehabilitation from the acute phase to excellent physical readiness, enabling them a quality return to sport. Once rehabilitation is complete, we also focus on preventing future re-injury of the anterior cruciate ligament (ACL).

The bony structure of the knee is provided by the femur, tibia, and patella, which are connected by soft tissues. One of the four key ligaments that provide passive stability to the knee joint is the anterior cruciate ligament. The anterior cruciate ligament runs down the middle of the knee and its main function is to prevent the tibia from sliding anteriorly, in front of the femur, whilst providing rotational stability to the knee.

An injury affecting the anterior cruciate ligament is a partial or complete tear of the knee ligament. It can happen to people of any age, including children. Women are 2x more likely to suffer the injury – studies suggest this is due to differences in muscle strength and pelvic structure. ACL injuries tend to happen during sporting activities involving agility or contact. We are talking about the combination of weak thigh muscles with movements such as jumping, kicks, lunges, and falls. This happens for example in gymnastics, football, basketball, skiing, etc. Practically any activity where the individual ” incorrectly” lands after a jump or performs a rapid change of direction or rotation in the knee can be fatal (1).

It is essential to emphasize that the choice of treatment is always individually determined, as until recently it was widely believed that all anterior cruciate ligament injuries required surgical treatment. Studies suggest that this is not the case, and the decision is always influenced by several factors. Knee surgery and ACL reconstruction are usually not considered if the patient is over 35 years of age, has no other intra-articular injuries, and is not highly physically active.

In other patients – that is, younger, physically active patients who want to continue their activity and have other injuries in the knee joint in addition to the anterior cruciate ligament rupture – we often opt for surgical treatment with anterior cruciate ligament reconstruction (2).

At Medicofit clinic, we believe that the number of how many individuals returning to their previous sports activities could be higher if physiotherapy and kinesiology rehabilitation after knee surgery was of high quality and consistently delivered. Below we would like to present to you the 7 most common mistakes that, if avoided, would improve the outcome of rehabilitation after ACL reconstruction.

1. 
   

   Not providing pre-operative rehabilitation and physiotherapy

 If you decide to have knee surgery, the fact is that you will have a better recovery if you have at least 5-8 weeks of supervised, high-quality pre-operative rehabilitation after your knee has settled down from the acute injury (4).

Pre-operative rehabilitation under the supervision of physiotherapists and kinesiologists is advocated and implemented at Medicofit for all ACL (anterior cruciate ligament) injuries in athletes. There are several studies in favour of the positive effects of pre-operative exercises, including one in 2016, which followed patients for 2 years after ACL reconstruction. Individuals in the group who underwent a 5-week kinesiotherapy programme based on progressive loading and incorporating neuromuscular rehabilitation principles had significantly better results than those who did not undergo exercise before knee surgery. In order to be ready for reconstructive surgery, they had to have, among other things, full knee mobility and 70% of the strength of the anterior thigh muscle, relative to the intact leg. As many as 72 % of those who performed preoperative exercise returned to their pre-injury sport (4).

Preoperative management in the physiotherapy and kinesiotherapy unit is therefore crucial in ensuring a good outcome of knee surgery. In particular with proper physiotherapy and kinesiology we can improve muscle activation in the accute phase after surgery and reduce waste of muscle mass.

2. Failure to perform isolation knee extension exercises in post-operative physiotherapy and kinesiology

Nowadays it is very fashionable, in terminology and also in practice, to include so-called “functional exercises” in exercise units. Movements which, with regard to the lower limbs, are mainly performed in a closed kinetic chain. This means that we keep our feet on the ground and perform squats, dead lifts, etc. The exercises consist of multi-joint movements and naturally play an important role in successful rehabilitation. However, when conducting rehabilitation after anterior cruciate ligament reconstruction, we must not forget the important role of isolated exercises for the anterior and posterior thigh muscles.

After ACL reconstruction, negative changes occur in the body in terms of tissue structure, neurological signalling and muscle physiology. The loss of the primary anterior cruciate ligament is reflected in muscle inhibition and at several levels of the nervous system. The key to reversing such negative changes that occur after knee surgery is to isolate the muscle using techniques that elicit muscle activation and thus with that, tissue regeneration (7)

At Medicofit clinic, in the physiotherapy department, we use muscle electrical stimulation immediately after knee surgery. In addition to physiotherapy treatment, our speciality lies in our close connection with the well-equipped kinesiology centre within the clinic. By performing exercises on the knee extension machine, we focus on sufficient strength of the anterior thigh muscle, which is the basis for any further functional movement in terms of running, jumping, multidimensional fast movement, etc. At the same time, by checking the weight that the individual can overcome in a given period, it also allows us to monitor the progress accurately. For example, with elastic band exercises, we cannot know exactly how much is, say, 60%, 70% or 90% of our maximum. With the devices, however, we have a precise overview, which is of paramount importance for guiding the rehabilitation process of the anterior cruciate ligament (ACL).

3. An anterior cruciate ligament (ACL) rehabilitation programme does not include plyometric exercises

Here we would like to present the case of a female patient at Medicofit clinic after anterior cruciate ligament reconstruction on both legs.

We carried out a secondary rehabilitation programme with the patient, who was a young basketball player. The patient was found to have thigh muscle weakness, knee instability and severe knee

valgus position in squatting and push-off jumping (i.e. the knees are inwardly rotated towards each other). During the rehabilitation, we improved the muscle strength of the knee joint extension and flexion by more than 150 % and achieved 95 % symmetry of both legs. With the collaboration of kinesiologists and physiotherapists, the criteria for the plyometric part of the rehabilitation was achieved by progressive loading. The patient successfully made the transition to running, rapid changes of direction and more advanced forms of plyometric exercise such as variations of single-leg lunges and high jumps. After completion of the rehabilitation, we functionally tested the patient.

The rehabilitation programme should necessarily aim at more demanding exercises that prepare the athlete – whether recreational or professional – for the stresses that lie ahead. To return to unpredictable sporting situations without carrying out plyometric exercises under the supervision of kinesiologists and expecting a good outcome is simply pointless.

4. Returning too quickly to previous sporting activities

The fourth mistake is in relation to some extent to the previous one. We understand that everyone wants to get back to pain-free daily activities or back to sporting activities quickly. However, rehabilitation after ACL reconstruction is a long lasting process. It is impossible to predict exactly how long rehabilitation will take, but it usually takes 9 months to reach sufficient criteria to return to sporting activities, according to studies and experience. 

5. Not providing sufficient psychological support

Individuals’ expectations of anterior cruciate ligament ACL reconstruction are high and often exceed the average results reported in the literature. Explicit information about realistic goals after knee surgery from physiotherapists, kinesiologists and other health and sports professionals is essential to prevent dissatisfaction. Honest communication of realistic goals is important, especially with young, active athletes for whom this is the first knee surgery (5).

In any injury, the psychological factors surrounding the situation must also be taken into account. The injury and the subsequent surgery make it impossible for the athlete to train and compete. For some, this means a loss of income, a complete change of lifestyle and worries about the end of their career. If individuals are not 100% confident in their knee at the end of rehabilitation, it means they will be less active, have poorer performance and muscle strength, all leading to an increased risk of re-injuring the anterior cruciate ligament in the next two years (8).

The collaboration of professionals from multiple disciplines such as medicine, psychology, physiotherapy, kinesiology, dietetics is crucial to address all the needs of the individual and to successfully return to an active lifestyle.

6. Measurements not taken since the end of rehabilitation after knee surgery to assess fitness to return to sporting activities

 The success of anterior cruciate ligament rehabilitation is always measured in terms of the functional capacity of the individual.

At Medicofit, we believe that the measure of a successful rehabilitation is the sufficient functional fitness of the individual, not the time spent in rehabilitation. Measurements at the Medicofit clinic are performed in the physiotherapy department after the first phase of treatment and in the kinesiology department before the return to sporting activities. Physical fitness can be measured by various functional tests to determine whether an individual is ready to return to previous activities (9).

For example, if returning to running, they should be able to perform at least 15 repetitions of the one-legged squat, at least 20 repetitions of the one-legged small bridge, at least 20 repetitions of the one-legged toe raise, and at least 15 repetitions of the one-legged vertical and forward jumps. In the return to professional sports, the tests and criteria are understandably even more demanding. In general, for a return to sport, we aim to achieve at least 90% symmetry in strength relative to the uninjured leg.

7. Not carrying out preventive exercise to prevent re-injury of the ACL

A case study of 242 patients under 18 years of age who underwent ACL reconstruction showed that 30% suffered another injury to their ACL graft, opposite knee or both within the next 15 years (6). Knee surgery is therefore not a 100% guarantee of success. The key is to attend physiotherapy regularly and exercise under the supervision of kinesiologists for the first year after ACL reconstruction, knowing that strength and conditioning will need to be maintained regularly – 2-3 times a week – for as long as we still want to play sport.

We would all like to hear that there is a magic trick or a special exercise that will fix all problems, but unfortunately, this is not the case. Adam Culvenor said, “The best exercises are the ones we do.”

So the “magic trick” will happen when you entrust your rehabilitation to physiotherapists and kinesiologists who don’t mislead you, who know what they are doing and, above all, who understand the process of progressive loading. So progressive in the way they perform and adapt exercises. This way, the rehabilitation plan after knee surgery will be properly adapted to your specific condition. 

Your job is to take your rehabilitation after ACL reconstruction extremely seriously and to follow the set program regularly and consistently. This is the only way to expect adequate progress and, if you are an athlete, a successful return to sport (3).

1. ACL infographic. Available at: https://www.mickhughes.physio/single-post/2019/11/25/acl-infographic
2. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48:1543-1552.
3. Eitzen, I., Moksnes, H., Snyder-Mackler, L., & Risberg, M. A. (2010). A progressive 5-week exercise therapy program leads to significant improvement in knee function early after anterior cruciate ligament injury. The Journal of orthopaedic and sports physical therapy, 40(11), 705–721. https://doi.org/10.2519/jospt.2010.3345
4. Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, Huston LJ, Spindler KP, Snyder-Mackler L. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction? A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts. Am J Sports Med. 2016 Oct;44(10):2608-2614. doi: 10.1177/0363546516652594.
5. Feucht MJ, Cotic M, Saier T, Minzlaff P, Plath JE, Imhoff AB, Hinterwimmer S. Patient expectations of primary and revision anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016 Jan;24(1):201-7. doi: 10.1007/s00167-014-3364-z. Epub 2014 Oct 2. PMID: 25274098.
6. Morgan MD, Salmon LJ, Waller A, Roe JP, Pinczewski LA. Fifteen-Year Survival of Endoscopic Anterior Cruciate Ligament Reconstruction in Patients Aged 18 Years and Younger. The American journal of sports medicine. 2016 Feb;44(2):384-92. PubMed PMID: 26759030. Epub 2016/01/14. Eng
7. Noehren B, Snyder-Mackler L. Who’s Afraid of the Big Bad Wolf? Open-Chain Exercises After Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2020 Sep;50(9):473-475. doi: 10.2519/jospt.2020.0609. PMID: 32867579.
8. Paterno MV, Flynn K, Thomas S, Schmitt LC. Self-Reported Fear Predicts Functional Performance and Second ACL Injury After ACL Reconstruction and Return to Sport: A Pilot Study. Sports Health. 2018 May/Jun;10(3):228-233. doi: 10.1177/1941738117745806. Epub 2017 Dec 22. PMID: 29272209; PMCID: PMC5958451.
9. Welling W, Benjaminse A, Lemmink K, Dingenen B, Gokeler A. Progressive strength training restores quadriceps and hamstring muscle strength within 7 months after ACL reconstruction in amateur male soccer players. Phys Ther Sport. 2019 Nov;40:10-18. doi: 10.1016/j.ptsp.2019.08.004. Epub 2019 Aug 9. PMID: 31425918.