ACL Rehab: Compliance, Time & Quality = Improved Outcomes.
As a clinician I often see a gradual decline in follow-ups with ACL reconstruction patients between 3-6 months post-op - despite best efforts to maintain patient motivation. The reasons for patient attrition are no doubt multi-factorial; escalating medical costs, family, work & life commitments and waning motivation; are reasons just to name a few.
The good news for both clinicians and patients, is that new research has shown that if the patient can maintain motivation to attend regular supervised rehab for at least 6 months, the strength and function gained during this period puts them in a position where they are highly likely to safely return to their pre-injury sport at 12 months.
A recent study of 111 non-elite ACL reconstruction patients showed that only 55% attended supervised rehab for at least 6 months post-op, and only 30% of these patients conducted supervised jumping, landing and agility training. The most interesting thing to come out of this study was that nearly all of the patients who conducted at least 6 months of supervised rehab were able to achieve >90% limb symmetry on strength and hop tests at 12 months post-op up testing, whereas the 45% of patients who conducted only 3 months or less supervised rehab; were only able to achieve <85% limb symmetry on all strength and hop tests at 12 months post-op. (Ebert et al., 2017).
This is an interesting finding in a non-elite cohort, as this suggests that longer, supervised rehab times (min. 6 months) of higher quality content (rehab including jumping, landing, agility), allows the patient to achieve greater strength and function of their reconstructed knee, thus putting themselves in a better place to return to sport at a later date.
This is on the back of recent research of 2nd ACL injuries in elite athletes, showing that players who achieved 90% or greater limb symmetry on strength and hop tests have a significantly reduced risk of future ACL injury compared to those who return to sport despite not achieving 90% limb symmetry on strength and hop tests (Grindem et al, 2016 & Kyritsis et al, 2016).
When you combine the above research findings with another current study (summarised below), it makes absolute sense that we encourage our patients to strive for high levels of strength and function via QUALITY and CONSISTENT ACL rehab.
Nawasreh et al (2017), revealed that 81% of non-elite ACL reconstructed patients who were able to return to their pre-injury sport at 12 months post op, achieved >90% limb symmetry on all strength and hop tests (measured at 6 months post-op), compared to only 44% who were able to return to pre-injury levels of sport without passing all of the strength/hop tests.
Take home message
In summary, ACL rehab is bloody tough, but if you can stick it out and perform at least 6 months of high quality strengthening and conditioning under the guidance of a good physio and exercise physiologist/S&C coach, the hard yards you put in during this 6 months will pay dividends and you’ll set yourself up for a likely return to your pre-injury sport after 12 months. Of course I'm not saying stop rehab after 6 months (ideally, you keep working your butt off until 12 months post-op and beyond), but the rehab can, and should, become more independent on your behalf and less supervised from us health professionals.