The Void in ACL Recovery

I’ll start off by saying that ACL recovery is personal for me as I have suffered ACL tears in both knees. Looking at the staggering statistics of second ACL injuries, it makes me wonder how many can potentially be avoided with improved physical therapy. Research provides a range of second ACL injuries which includes re-tears of the same knee and tears of the other knee. Three different studies reported second ACL injury rates of, 14.1%(1), 20%(2) and 29.5%(3) respectively. These second ACL injuries occur due to a variety of modifiable reasons including, lack of full range of motion, muscle weakness/imbalances, poor landing mechanics, lack of conditioning and improper assessment of return to sport testing. All these factors SHOULD be addressed in physical therapy before an athlete is cleared for sports to give them the best possible outcome.

Most PT facilities provide care which can get the patient back to running but not much beyond. In most clinics, their capacity to challenge athletes in late stages of ACL rehabilitation is limited due to lack of open space, equipment and weights. Additionally, many therapists lack the knowledge for advanced progressive exercises to continually challenge athletes and additionally fail to perform return to sport testing. I personally believe many outpatient therapists are not qualified to treat an ACL reconstruction in its entirety. Most therapists do not dive into ACL recovery research, meaning they lack the knowledge to eliminate the risk factors associated with second ACL tears. It’s no different than me treating an advanced stroke or TBI patient, I wouldn’t feel qualified and likely be doing the patient a disservice because I haven’t tried to learn more on the subject. On several occasions, I’ll get a new ACL patient from another facility who still lacks full extension at over 5 months after surgery, only to find that their therapist told them that’s as good as it gets. This frankly is unacceptable and puts these young athletes at risk for a second ACL tear. Achieving full knee extension is one of the foundational components of full ACL recovery as it dictates whether you can fully regain quad strength and whether your gait/movements can return to normal. GOOD ENOUGH IS NOT ENOUGH.

Numerous ACL patients have told me they stopped going to their previous physical therapy because it got too easy and repetitive. The patients that stop going to therapy end up doing basic rehab on their own or don’t do rehab at all. Then, at around 7-9 months the surgeon clears them for sports when they’re not remotely close to ready. These patients are the ones that feed into the overwhelming second ACL injury statistic. Athletes NEED to be challenged during ACL recovery to properly prepare them for return to sports and reduce secondary ACL injury rates.

What’s the alternative for later stages of ACL recovery? Finding the right type of facility and therapist that will consistently challenge patients in physical therapy is the first step. Sports physical therapy is a specific niche and requires both the right therapist and facility. I work in a facility that has a 40-yard turf field and extensive weight room allowing me to consistently challenge my athletes during ACL recovery. My goal at the end of therapy is for the patient to be STRONGER than they were prior to the injury and be fully confident in returning to their sports.

I focus on progressive strengthening and stability of the hips, quads, hamstrings and calves, challenging each muscle in different ways. Research reports “reducing limb asymmetries before returning to sport appears imperative for maximized performance and reduction of secondary ACL injury risk,”(4) and “reinjury rate was significantly reduced by 51% for each month return to sport was delayed until 9 months, after which no further risk reduction was observed.” (4) Additionally, I ensure my patients have sound jumping and landing mechanics with eventual successful completion of return to sport testing. Athletes who successfully complete return to sport testing are nearly 35% LESS likely to suffer a second injury compared to those who don’t successfully complete the testing. (5)

Secondary ACL injury rates are significantly too high, and I believe those numbers can be improved upon through a sound ACL rehabilitation program. Finding the right sports physical therapist in the right facility can significantly decrease the risks of second ACL injuries. I personally believe every ACL patient should be in rehab for a minimum of 9 months as there is so much to address in order to ensure optimal recovery. Research provides us with evidence-based guidelines which are proven to significantly reduce the risk of second ACL tears.

For more information and to see a typical late-stage ACL physical therapy session with me, https://www.wesleywangdpt.com/post-operative-acl-recovery

Thanks for reading.

-Dr. Wesley Wang, PT, DPT

Sources:
1. Hettrich C, Dunn W, Reinke E, MOON Group, Spindler K. The Rate of Subsequent Surgery and Predictors Following ACL Reconstruction: Two- and Six-year Follow-up from a Multicenter Cohort. Am J Sports Med. 2013 Jul:41(7):1534-1540.
2. Wiggins AJ, Grandhi RK, Schneider DK, Stanfiel D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul:44(7):1861-76.
3. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. AM J Sports. 2014 Jul:42(7):1563-73.
4. Wiggins AJ,Grandhi RK, Schneider DK, Stanfiel D, Webster KE, Myer GD. Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis. Am J Sports Med. 2016 Jul:44(7):1861-76.
5. Hettrich C, Dunn W, Reinke E, MOON Group, Spindler K. The Rate of Subsequent Surgery and Predictors Following ACL Reconstruction: Two- and Six-year Follow-up from a Multicenter Cohort. Am J Sports Med. 2013 Jul:41(7):1534-1540.