Getting Back on the Court: PT for ACL Rehabilitation
On Saturday 2 NBA starters, including last year’s league-MVP, went down with ACL tears. The ACL is one of the 4 vital ligaments supporting the knee. For a professional athlete, an ACL tear usually means surgery to reconstruct the knee followed by 9-12 months of rehab in order to get back to playing shape. There’s no guarantee of returning to pre-injury levels, but minimally-invasive surgeries and improved rehab techniques have significantly increased athletes’ likelihood of continuing prosperous careers despite this brutal injury. Many factors determine success rates after an ACL injury, such as:
- Pre-injury conditioning
- Concomitant injuries, such as meniscus, bone or other ligamentous damage
- Surgical technique and graft source – using a portion of the patient’s patella tendon or a cadaver ligament to replace the torn ACL
- Rehab approach – aggressive vs. conservative
- The patient’s response to every step through the process
- Emotion and psychology play a huge part in recovery from this injury. A year of recovery requires consistent hard work and commitment to get back on the court.
From a PT perspective, we typically follow general guidelines or protocols that have been proven successful over the years. Still, every patient is different, and they each require attention to their particular response to surgery, PT and life. We work to assist, coach, guide and encourage the patient on this long road. We use manual techniques to reduce swelling and restore range of motion. We progressively teach the patient to recruit muscles that become dormant after surgery. We gradually add strengthening exercises, balance drills and eventually movements and activities that simulate game action.
Kevin Wilk, PT, DPT, along with Dr James Andrews, MD and others, published a paper in the March 2012 Journal of Sports PT, entitled “Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries.” The paper summarizes years of experience backed by scientific rationale for their ACL protocol. In the paper they outline some things they’ve found that improve recovery speed and increase the likelihood of a successful recovery:
- Achieving homeostasis prior to surgery – usually 21-day program
- Reducing swelling
- Restoring range of motion
- Achieving normal muscle strength in the knee and hip regions
- Following a program that emphasizes:
- Reducing inflammation
- Full knee extension or hyperextension in the first few days
- Full passive range of motion 4-6 weeks post-op
- Normal patella mobility
- Re-establish voluntary quadriceps control
- Restore neuromuscular control
- Gradually increase applied loads
- Sport-specific training
Some tools that can assist through this process are systems that can control weight-bearing, such as aquatic therapy or an Alter-G treadmill. Regular icing and self-care by the patient are vital throughout the rehab process. It is also absolutely necessary for the PT to listen to their patient. When the patient is sore or swollen, that should be addressed and the program intensity should be increased or decreased according to the patient’s pattern of response. When they report feeling great, they should be congratulated and empathy and encouragement help any patient through a bump on the road to recovery.
The above outline is not the only means of rehabbing an ACL reconstruction, but it has been successful with the majority of patients treated this way. Considerations need to be made for concomitant injuries, other types of surgical techniques and females.