Are you like one of the many Melbournians who ruptured their ACL in 2017?
No? Well you probably know someone who’s going through their rehab or wearing one of those huge knee braces…
A common question I get asked as an osteopath is; “When do you think I’ll be able to get back to running/cricket/footy/netball etc.?”
If there was a clear-cut rehabilitation program which guaranteed a smooth, risk free transition back to sport none of you would be reading this article.
Unfortunately, the gold standard just doesn’t exist yet, however, we are lucky to have access to the newest research.
This give us, your osteopaths and physiotherapists the right information to guide your rehab program and give you the highest chance of success.
“So what does the newest research suggest?”
The traditional return-to-sport (RTS) criteria mainly focuses on a time frame period in conjunction with clinical assessments of physical capability. Often you hear those who’ve had their reconstruction saying, “In 12 months I’ll be back, once all the locking, swelling and restrictions are gone.”
The latest research from Burland et al. (2017) is suggesting to take more of an “optimized criterion-based multifactorial return-to-sport approach” (p. 2). A layered tactic with a broader criterion, where the athlete performs repeated evaluations, a gradual reintroduction into sport, all while taking into account the multiple biopsychosocial factors Burland et al. (2017).
A biopsychosocial approach to rehabbing an ACL reconstruction looks like this:
- Patients together with their support group and practitioner should discuss what their specific definition of RTS is, so that the desired outcome becomes the main focus and the rehab program is tailored to this.
- These goals should be discussed throughout the process of rehab and not at the end of the program, as this ensures consistency, motivation and ongoing care.
- Changing the traditional 6-12-month timeline for RTS to a minimum of 9 months plus the time taken for the patient to meet all RTS criteria to a high standard.
- Completing a thorough and ongoing clinical evaluation of the patient. The literature is now recognizing a stronger correlation between assessing the psychosocial aspect as well as the physical, and improved results in returning to pre-injury levels.
- Psychological stressors
- Fear of re-injury
- Psychological readiness associated with RTS
- Motivating factors
- Lifestyle changes
- Full range of knee motion
- No pain
- No swelling
- No abnormal laxity on testing
- Combining a patient-reported outcome measure (PROM) with objective performance-based measurements to help document subjective and objective improvements. Low outcome measures shouldn’t be allowed to progress.
- Examples of PROM’s include: self-re- port questionnaires that measure an individual’s perception of symptoms, function, activity, and participation
- Objective performance-based measurements are tests such as the; hop test, muscle strength, limb symmetry index and assessment of movement quality.
- Movement quality – The knee doesn’t just work as an isolated joint, but more of an intermediate one within a system. When stressed by different movement patterns each part of system responds differently. Once you add in uneven surfaces, huge opposition or balls flying every which way, those systems need to able to adapt and take on more force than just your body weight. To RTS all movement should be of the highest possible quality. Assessing movement pattern’s when fatigued is also vital.
- Sport reintegration – most of you will want to rush into this! Only when the above criteria have been met to a high level should you be making this next step. Even then it is a slow process and steps 3 and 4 should be continued all the way through this.
- Return to reduced team training without contact
- Return to full team training with contact
- Return to friendly games (initially not over the full duration)
- Return to competitive games (initially not over the full duration
Burland et al. (2017), Dingenen, B., & Gokeler, A. (2017), DiFabio et al. (2018)
Exactly what makes an osteopath or physiotherapist the right practitioner to help me in my rehab program?
Well even though some might say I’m little biased in my opinion, I do believe our osteopaths and physiotherapists are a fantastic option when rehabbing any injury. At the start of the initial session it is really important that together we decided on a clear goal, so we both know where we are headed. In that first session we also discuss the patient as a whole person to understand the factors affecting their injury, their body and their life. From here on we examine the knee and the systems it is a part of, to see how they impact one another. We base our treatments off these findings and the following principles; the body is a unit, the body has its own ability to heal and regulate itself and that structure and function are reciprocally related. The psychosocial factors are always at the forefront of our minds and naturally we are very holistic in our approach. Don’t let someone rush you back or into a new exercise that you’re ready for. The best practitioners are the ones who are not only up to date with the research but they are the ones that care about you and know you deserve to feel good.
So if you are someone coming back from an ACL reconstruction or you know someone in that situation, recommended a good osteopath or physiotherpist to ensure that they are receiving the best care possible.
Burland, J., Toonstra, J., Werner, J., Mattacola, C., Howell, D., & Howard, J. (2018). Decision to Return to Sport After Anterior Cruciate Ligament Reconstruction, Part I: A Qualitative Investigation of Psychosocial Factors. Journal Of Athletic Training. http://dx.doi.org/10.4085/1062-6050-313-16
DiFabio, M., Slater, L., Norte, G., Goetschius, J., Hart, J., & Hertel, J. (2018). Relationships of Functional Tests Following ACL Reconstruction: Exploratory Factor Analyses of the Lower Extremity Assessment Protocol. Journal Of Sport Rehabilitation, 1-7. http://dx.doi.org/10.1123/jsr.2016-0126
Dingenen, B., & Gokeler, A. (2017). Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Medicine, 47(8), 1487-1500. http://dx.doi.org/10.1007/s40279-017-0674-6