Most people who know me as a coach will know how passionate I am about knee injuries, both in prevention and in treatment.
Over the past few years in particular I have spent a lot of time, thought and research (reading) trying to figure out the absolute BEST way to treat the ACL pre-surgery and post surgery to both limit timeframes of recovery but most importantly, to increase the rate of recovery pre-surgery so that a few key things are done:
- Range of motion being full. At Vector Health and Performance (VHAP) this is usually the Physiotherapist’s role initially. So, as soon as someone has a suspected tear, rupture of ACL, we focus first on range of movement in flexion and extension. WHY? Have you ever tried kneeling with one knee that will not bend fully? It is annoying. OR.. .have you ever tried to work with one leg that straighten’s fully and one that is missing 5-10 degrees of extension? It is painful, annoying and very lifestyle limiting. So, this is our first focus. The surgeons that we specifically work with, The McMeniman brothers (Peter and Tim) are also very big advocates of the pre-surgery rehabilitation process and their record of recovery speaks for itself.
- If there is meniscal irritation or tears then we need to be mindful of the next stage, which is working on both knee stability, balance and strength (neuromuscular coordination here is the KEY). Meniscus irritation will limit sometimes the amount of hamstring work that can be done prior to surgery, due to the strain this can put towards meniscal injuries. Not saying we do not do any work on hamstrings, but we might delay the onset of this work somewhat depending on symptoms of each person.
- Glutes – the power house of the human body! The forgotten weapon of an athlete most of the time. Well… the key here is to develop them, strengthen them and make them STRONG! Glute Strength is important, because it lends itself to better knee stability, better hip extension capability and better landing and balance ability. WHY? Because it provides the link with a concept called hip hinging. Too many athletes, high through their knee and lumbar spine rather than from hip to knee. The hip is without doubt the biggest and strongest joint in the body. It has the biggest muscles in the body surrounding it and SHOULD be responsible for the initiation of a lot of critical movements ESPECIALLY landing, but this is too often not the case. So, we strengthen the GLUTES> Not necessarily making them bigger, but making the connection between the brain and the Glutes better, faster and more dominant in movement orientation.
A recent study by Filbay, Roos et all that has been published in the British Journal of Sports Medicine reveals some very interesting findings. The journal article can be found HERE
This study looked at 5 year prognostic outcomes post ACL rupture. The researchers explored the relationship between prognostic factors:
a. Baseline Cartilage, meniscus and Osteochondral damage
b. Baseline extension deficit
c. Baseline patient-reported outcomes
d. number of rehabilitation visits
e. graft/contralateral ACL rupture
f. non-ACL surgery and ACL treatment strategy
g. 5 year Knee Injury and Osteoarthritis Outcome Score (KOOS) pain,
h. Symptoms
i. Sport/recreation and quality of life scores
Some of the key findings were:
A graft/contralateral ACL rupture, non ACL surgery and worse Short Form Mental Component Scores were associated with worse outcomes.
Treatment with exercise therapy alone was a factor for LESS keen symptoms compared with early reconstructive plus exercise therapy.
Baseline meniscus lesion was associated with worse sport/recreational function
Osteochondral lesions were associated with worse outcomes following early reconstruction plus exercise therapy.
Undergoing additional non-ACL surgery and worse KOOS scores were prognostic for worse outcomes.
HOWEVER: Important to note:
Following Delayed reconstruction, baseline meniscus damage was a prognostic factor for LESS pain.
Following Exercise therapy alone, undergoing NON-ACL surgery was prognostic for worse pain.
The researchers concluded that it was important to individualise more the treatment plans for ACL rupture patients.
This is important to note though. This research study has probably posed more questions necessarily than answers. What I personally have taken away is that one of my biggest and most important pieces of advice to people has been, “do the work before surgery so that the work after surgery is easier.”
Our pre-surgery program is focused on three parameters:
- Range of motion and appropriate flexibility. Where possible go back to mobility that was pre-injury and flexibility that is pre injury or better. Particular areas to focus on are:
- Ankle Joint – calf, ankle joint capsule
- Hamstring, Piriformis, Glutes
- Quadriceps and in particular Hip Flexors
- ITB – mobilise to stop dominance and internal rotation at knee joint.
- Weight Bearing – walking normally as physically possible. Let swelling settle as much as possible, try to get back to pre-injury prior to surgery. This is part of the ability to take on strength or resistance loading prior to surgery.
- Increase strength of the following:
- Glutes – close chain hip extension dominant actions – bridging from floor, bench, loaded bridge activities, romanian deadlift as progressions.
- VMO – medial or inside quadricep muscle. AND – Glute Med – helps control hip external rotation and stability (non-valgus) of the knee joint in balance, stance and squat patterns. Things like: clams, band walks, side lying leg raises, squats with bands around top of knee. Wall squats with bands, isometric loading, progressing if possible to single and uni-lateral exercises prior to surgery is a sing of success!
- Keep Quad Bulk especially and muscle bulk on affected side. AND work just as hard on non-affected side. One of the things this study did not compare was the number of athletes who then rupture the other side within 5 years of going back to sport. You are more likely to rupture the other side once rupturing one of you ACL’s. So work on the other side just as hard.
Case Study in point:
One of our Rugby athletes, ruptured their ACL in a rugby league game earlier in the year. Due to factors probably out of his control, his surgery has been delayed nearly 4 months. He is an exceptionally strong human being, having a pre-injury strength record of a 240kg squat, 165k bench press, 240kg deadlift, and a 130kg Olympic Clean Power Pull previously. He could run 20m in just over 3 seconds and scored well above average in fitness testing (Yo-Yo) for a prop forward compared to a super 15 level athlete.
His ACL was ruptured, MCL was torn. He has some issues with the retinaculum around patella as well. No meniscus injury. Severe pain at time of injury and up an walking within 4 days of injury though. Initially, the plan was to improve Range of Motion and try to get him to walk to help him return to work.
A rough timeframe post injury is:
2 weeks without gym or any other exercise modality – focused on recovery, icing and keeping leg up.
Within 1 week, range of motion had returned to within 5 degrees of extension and within 15 degrees of flexion. Was able to walk reasonably well with one crutch at end of first week.
End of second week, was able to fully extend knee after warming up and doing some exercises to help. Flexion was almost back to normal. Swelling significant reduction. Decision made to return to work with some restrictions.
Week 3, starting of some baseline strength work to improve Glutes, VMO, Glute Med and also some more active mobility work of hip and ankle. Returned to gym with no more than 75% of 1RM loading on upper body to help body focus on recovery. We knew at this point that surgery would not be soon and so the focus was to improve strength and get back to what we could.
We worked on a basic level program of strength using isometric and closed chain only work for 4 weeks. At end of 4 weeks he could comfortably perform full bodyweight squats, full range of knee, walk properly, no limp and was able to jog. We stopped jogging due to concerns of some instability that was still present. He could balance on once leg for 30 seconds without any significant valgus, but not good enough that it was acceptable to start running.
Week 7 – started back romanian deadlifting and deadlifting in the gym. Posterior chain focus. First session back did 40% of his pre-injury 1RM loading for 10 reps comfortably. Still worked on the basics now as a warm up. The old “rehab strength” program now became the warm up for lower body work in the gym.
Week 8 – started to run and was able to run easily, no pain or instability. Wore a brace to help with the feeling of security.
At Week 10, added in some weighted squats with a barbell and since this time has progress to the following. We are approximately 15-16 weeks injury at time of writing I believe.
Has box squatted 200kg for 2 reps. Deadlifted 220 for multiple single reps and back to doing olympic weightlifting, playing touch football and has gone back to test his knee doing some contact work at training. Has not played due to concerns of sustaining further damage, but you could argue he could.
The reason that I wanted to share this with you, is that it emphasises without going into too much detail what can be achieved over a relatively short time. Surgery is booked for this athlete and we are very confident of the outcome being great, due to his physical state pre-surgery. I would almost argue that whilst the wait has not been ideal for his rugby career, it may be the best thing in terms of extending his rugby career and giving him a better long-term prognosis.