Just Tore Your ACL? Do These 4 Things Before Surgery

Many athletes feel helpless after they tear their ACL. These steps can help them regain a sense of control and shift into a proactive mindset.

The period after an ACL injury can be a difficult time.

While your mind is full of questions as to your future in sport or what procedure to undergo, there are a few simple actions you can take to gain control of the situation.

It may be hard to make decisions when you've just ruptured your ACL, but taking a few simple steps, guided by a medical professional, can improve your chances of not only returning to your sport, but achieving or surpassing your previous levels of performance.

Read More >>

The period after an ACL injury can be a difficult time.

While your mind is full of questions as to your future in sport or what procedure to undergo, there are a few simple actions you can take to gain control of the situation.

It may be hard to make decisions when you've just ruptured your ACL, but taking a few simple steps, guided by a medical professional, can improve your chances of not only returning to your sport, but achieving or surpassing your previous levels of performance.

1. Make Note of Your Baselines

There is a huge difference between simply returning to sport and returning to your previous level of performance.

While much of the medical literature has focused on those who return to sport, there is mounting evidence that many athletes have shorter careers and perform at a lower level following ACL reconstruction. Yet some have managed to come back better following a torn ACL.

The more data you have to inform the decisions you make during your rehab and subsequent return to sport, the better off you'll be.

Make note of the most recent metrics you have, from your 1RMs in the weight room to 40-Yard Dash times, Broad Jump maxes, agility shuttle times, etc. Even make note of things like game statistics.

Either put physical copies of all these things in a folder and keep it in a safe place or enter them into a digital document and save them on an easily accessible drive. All of this data can help you and your physical or athletic therapists quantify your progress during the long process of rehabilitation following an ACL injury or reconstruction.

2. Test Your Strength and Performance ASAP

Traditionally a limb symmetry index is used to determine when an athlete is ready to return to sport following ACL reconstruction. This is when the score of your injured leg is divided by the score of your uninjured leg in assessments like quadriceps and hamstring strength and hop tests.

Scores in the range of 90% or above are considered reasonable for the return to modified sports activity, with many advocating near perfect symmetry (100%) when returning to high-level, contact sport.

The limb symmetry index isn't perfect. Recent studies have found that it may overestimate your recovery as your uninjured leg may atrophy and detrain over the period of your injury and rehab, thus lowering the standard your injured leg has to achieve.

Using the strength and performance of your uninjured leg very shortly after injury may be a better marker for safe return to sport (6).

Researchers followed a group of 70 athletes over two years, measuring the strength and performance of the injured and uninjured legs both pre-surgery and at six months following ACL reconstruction.

Although 57% of athletes achieved 90% of their uninjured leg performance measured six months post-surgery, only 29% were able to achieve 90% of their pre-injury uninjured leg performance for quadriceps strength and hopping distance.

There are risks involved with performance testing so soon after ACL injury, even if the tests involve your uninjured leg. Find a physical or athletic therapist who has experience and is comfortable leading someone with an ACL injury through functional performance tests for their uninjured limb before attempting any performance-based testing while injured.

3. Rehab Can Start Now

In the early days following an ACL rupture, it can be hard to imagine returning to the gym, running or even sport. And yet those who start a prehabilitation program prior to their surgery may do better in the long run.

Patients who completed prehabilitation prior to ACL reconstruction in addition to post-operative rehabilitation had higher scores of knee function and a greater proportion ultimately returned to sport than those who did not complete prehab. A recent systematic review found much the same, that prehabilitation is safe and well-tolerated by those with ACL injuries, and may improve function prior to surgery.

Given that times from injury to surgery can vary significantly, and often depend on factors outside of your control, completing regular training sessions can improve the function of your ACL injured knee, stave off detraining of the rest of your body, and may improve your outcomes following ACL reconstruction.

You'll need the help of a professional who has experience working with ACL injured and reconstructed athletes to create and lead you through a prehabilitation program. Such a program will typically improve the function of your uninjured knee while also optimizing training effects for the rest of your body.

4. Raise Your Standards

If you've already started a prehabilitation program, you're on the right track.

Once the initial swelling has settled and range of motion is restored, much can be achieved with your ACL injured knee. Although there's no agreement as to what level of function you should have prior to surgery, researchers have used targets of 90% of the uninjured side's scores on quadriceps and hamstring strength test, and a collection of four hop tests (single hop for distance, triple hop for distance, triple crossover hop for distance, six-meter timed hop). It may not be reasonable to expect all patients to achieve these outcomes (73% in the original study did). Others have used 80% as an indicator of those who are coping well with ACL deficiency.

Data from the KANON trial supports this idea, finding similar outcomes up to five years after injury in those who had early ACL reconstruction, initial rehabilitation with delayed reconstruction, or those with rehabilitation only.

This data is not to convince you to forgo a reconstruction, but to show you what can be achieved without an ACL in the interval between your initial injury and surgery, which can extend for months depending on where you live. Those in elite sport or in contact or pivoting sports may ultimately require a reconstruction, but that doesn't mean considerable progress can't be made prior to surgery.

A Torn ACL Isn't the End

Although it may be difficult to imagine taking these steps so soon after an injury, participating in prehabilitation, having baseline indicators of your sport-specific and lower-body functional performance, and rethinking what can be achieved without an ACL may improve your likelihood of not simply returning to your sport, but thriving at it. Find a professional or team of professionals with experience at such procedures to maximize your odds of success.

Many athletes feel helpless after they tear their ACL. By taking these steps, you can regain a sense of control and shift into a proactive mindset.

References:

1. Mai, H. T. et al. "Performance-Based Outcomes After Anterior Cruciate Ligament Reconstruction in Professional Athletes Differ Between Sports." Am J Sports Medicine 45, 2226–2232 (2017).

2. van Melick, N. et al. "Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus." British Journal of Sports Medicine 50, 1506–1515 (2016).

3. Zwolski, C., Schmitt, L. C., Thomas, S., Hewett, T. E. & Paterno, M. V. "The Utility of Limb Symmetry Indices in Return-to-Sport Assessment in Patients With Bilateral Anterior Cruciate Ligament Reconstruction." Am J Sports Medicine 44, 2030–2038 (2016).

4. Wren, T. et al. "Hop Distance Symmetry Does Not Indicate Normal Landing Biomechanics in Adolescent Athletes With Recent Anterior Cruciate Ligament Reconstruction." The Journal of Orthopaedic and Sports Physical Therapy 1–23 (2018). doi:10.2519/jospt.2018.7817

5. Gokeler, A. et al. "A critical analysis of limb symmetry indices of hop tests in athletes after anterior cruciate ligament reconstruction: A case control study." Orthopaedics & Traumatology, Surgery & Research : OTSR 103, 947–951 (2017).

6. Wellsandt, E., Failla, M. J. & Snyder-Mackler, L. "Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury." The Journal of Orthopaedic and Sports Physical Therapy 1–18 doi:10.2519/jospt.2017.7285

7. Hiemstra, L. A., Webber, S., MacDonald, P. B. & Kriellaars, D. J. "Contralateral limb strength deficits after anterior cruciate ligament reconstruction using a hamstring tendon graft." Clinical Biomechanics 22, 543–550 (2007).

8. Shaarani, S. et al. "Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction." The American Journal of Sports Medicine 41, 2117–2127 (2013).

9. Shaarani, S., Moyna, N., Moran, R. & O'Byrne, J. "Prehabilitation: The Void in the Management of Anterior Cruciate Ligament Injuries—A Clinical Review." Isrn Rehabilitation 2012, 1–11 (2012).

10. Failla, M. J. et al. "Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?" Am J Sports Medicine 44, 2608–2614 (2016).

11. Alshewaier, S., Yeowell, G. & Fatoye, F. "The effectiveness of pre-operative exercise physiotherapy rehabilitation on the outcomes of treatment following anterior cruciate ligament injury: a systematic review." Clin Rehabil 31, 34–44 (2015).

12. Grindem, H. et al. "How does a combined preoperative and postoperative rehabilitation programme influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian National Knee Ligament Registry." Brit J Sport Med 49, bjsports-2014-093891 (2014).

13. Eitzen, I., Moksnes, H., Snyder-Mackler, L. & Risberg, M. "A Progressive 5-Week Exercise Therapy Program Leads to Significant Improvement in Knee Function Early After Anterior Cruciate Ligament Injury." J Orthop Sport Phys 40, 705–721 (2010).

14. Frobell, R. B. et al. "Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial." Bmj Br Medical J 346, f232 (2013).

Photo Credit: skynesher/iStock

READ MORE:


Topics: ACL INJURY | INJURY RECOVERY