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Updated September 2019
An ACL (anterior cruciate ligament) rupture is a devastating injury for anyone, and it immediately puts an athlete’s career on hold for an extended time. ACL injuries are a much more frequently occurring injury nowadays than they were 15 years ago.
There are many factors that contribute to this statistic including: increased artificial surfaces, more aggressive footwear, and increased training time to name a few. The two most common questions I am asked when treating a client who has had an ACL reconstruction are: “When can I start running?” and, “When will I be able to start playing/competing again?” This article intends to outline return to sport timelines and the many factors that determine the right time for an individual to safely return to competition following an ACL reconstruction.
What to Expect After ACL Surgery
As a general rule, return to sport after an ACL reconstruction does not occur until at least six months. During this 24-week phase, activity is slowly increased in accordance with each stage of healing. It is not until this 6-month mark that the newly created ligament is fully hardened and its anchors into the tibia and femur are well healed and strong. This period of time also allows the muscles crossing the knees, hips, and ankles to regain the strength and endurance that sports demand.
The most important aspect of this rehab process is that the individual performs all movement patterns with correct technique and body position. Several well-known studies have shown that individuals that have suffered an ACL rupture have a higher likelihood of a second ACL injury to same or uninjured leg in returning to sports than those that have not. The following predictive elements have been shown to contribute to re-injury:
Weak or altered firing patterns of the hip muscles and poor coordination of hip with trunk and lower leg leading to asymmetry between these joints as foot strikes ground
Decreased single-leg postural control
Poor landing technique (poor alignment of trunk, hip, knee and ankle)
Suboptimal neuromuscular control of knee and hip during single leg landings and cutting
Imbalance in length/tension relationship of muscles crossing hip and knee
It is important to note that, until the athlete is able to consistently reproduce quality athletic movement with each increasing stage, the program should not advance. The addition of more challenging exercises or sports-specific movements before good motor skills have been adopted can increase the likelihood of re-injury. The repetition of poor (uncorrected) motor patterns can be a large contributor to re-injury in many athletes that have suffered a secondary injury.
The ACL Reconstruction Timeline
An ACL protocol, created by renowned orthopedic surgeons Dr Fowler and Dr Kennedy, is a well-known guideline that many physiotherapists will follow; however, each surgeon can have slightly different protocols. Every patient is different and healing times also vary, so progressions are made according to how well the patient responds to each increase in activity or new exercise. Your physiotherapist will closely monitor your knee to ensure that it is ready for each progression. Any increase in pain, heat or swelling may be a warning sign that the surgical site is irritated and not tolerating the current activity level and should be adapted accordingly. The following is a general outline of how activity is safely increased during the ACL rehabilitation process.
0-6 Weeks:
Decrease pain and swelling
Increase range of motion and achieve full extension (straight knee)
Activate quadriceps and hamstring
Minimize limp/improve gait and begin proprioceptive/balance drills
Maintain flexibility of hamstring and calf
Maintain hip/glut strength via non-weight-bearing exercises
6-12 Weeks:
Functional strength of quads and hamstrings, e.g., mini wall squats, static half lunches and step-ups
Begin gentle hamstring resistance work, balance board drills
Various pool drills (if incisions FULLY healed)
Bike and pool used to improve cardiovascular fitness
12-16 Weeks:
Volume and intensity of activity is increased
Drills become more sports specific to increase strength, endurance and cardiovascular fitness
Agility drills such as ladder and footwork drills
Simple double-leg plyometrics can begin
16-24 Weeks:
Addition of sports-specific cardiovascular activity
Controlled single leg jumps/landings, resisted lifting and change of direction start
Agility drills begin with large angle/slow speed and progress to sharper angles/increased speed
Defensive or reactive type drills are final exercises introduced before return to play
Your Return to Sport Options
In returning to a team, an athlete should avoid any contact-type drills until they feel comfortable with the demands of full non-contact practices. The time it takes for an athlete to feel physically and mentally ready for full contact can vary, but it is important that the individual feel confident, strong, and fit before this occurs. Contact sport scenarios should occur first during practice and be well executed before the athlete is allowed to play in competition.
The decision to undergo ACL reconstructive surgery is a serious one and it is important for athletes that wish to return to sport to fully understand the lengthy timeline involved to ensure that this is done safely. The guidance of a sports physiotherapist will play a very important role in this process and will help ensure that specific physical requirements are met before allowing for this return. Overall the process can be quite challenging but also exciting for both the patient and therapist as the program progresses. With a bit of creativity, there are endless ways to combine sport specific movements with strength, endurance, and cardiovascular fitness to ensure that the athlete achieves the necessary goals and safely returns to their sport.
Karen Nichol, founder of Royal City Physio, graduated from the University of British Columbia with a Bachelor of Science in Physiotherapy. She is currently the head physiotherapist for Coquitlam Adanac Sr A's and head physiotherapist for the Police Academy at The Justice Institute of B.C. She is also a member of the Canadian Physiotherapy Association, and the Physiotherapy Association of B.C. Book with Karen today.