ACL
It is estimated that up to 300,000 ACL reconstructions are performed per year in the United States (3) with the highest injury rates occurring in female soccer players and male football players (1). Advances in surgical management and post-operative rehabilitation have resulted in ~70% return to athletic participation (5); however, there still exists a great degree of variability in return to prior level of athletic performance and sport. Some studies report ~50% return to previous sport level within 1-2 years or seasons with remaining athletic performance deficits persisting for up to 3 years/seasons (2).
Within 9-12 months, the anatomical and biomechanical properties of the post-operative knee have been restored, so why the delay/discrepancy in performance? If you’ve read any of my past blog posts, the answer may not be very surprising... yes, it’s strength. Longitudinal studies have demonstrated strength and muscle cross sectional area deficits in the quadriceps and hamstrings groups which can persist for up to 5 years post-operatively despite excellent surgical techniques and intensive rehabilitation (4). These deficits not only negatively impact athletic performance, but they predispose athletes to subsequent injury and reinjury.
While Physical Therapists are an essential part of the return to sport process, 1-2 visits per week of PT is not enough to return athletes to their previous level of function. Because of this, many youth athletes do not return to their prior level of athletic performance or have a delayed return to performance. Utilizing a strength and conditioning specialist or strength coach closes the gap between rehab and performance and can help to accelerate the return of strength and power necessary to optimize long-term outcomes. At the higher levels of competition, the team strength coach is built in. They are a consistent and essential part of the rehab process; however, at the sub-collegiate level, the presence of a dedicated strength coach is unlikely. In these cases, it is the responsibility of the orthopedic team (surgery and rehab) to educate the patient regarding this aspect of rehab and to initiate a referral if necessary.
Physical Therapists are great at what we do, but in the setting of ACL reconstructions, we need to understand the importance of utilizing strength and conditioning specialists to maximize our patient outcomes. As such, I would highly recommend the following:
If you work in orthopedics and sport, you need to have a strength and conditioning referral or recommendation.
Many of us at the Warwick clinic refer our patients to Andy Procopio and his team at AMP training center
If you’re a serious athlete and you don’t have a strength coach/personal trainer, find one. Injured or not, you need to be strong to stay in your sport or to return to your sport following an injury.
Works Cited:
1. Joseph, A. M., Collins, C. L., Henke, N. M., Yard, E. E., Fields, S. K., & Comstock, R. D. (2013). A multisport epidemiologic comparison of anterior cruciate ligament injuries in high school athletics. Journal of athletic training, 48(6), 810-817.
2. Klasan, A., Putnis, S. E., Grasso, S., Kandhari, V., Oshima, T., & Parker, D. A. (2021). Tegner level is predictive for successful return to sport 2 years after anterior cruciate ligament reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 29, 3010-3016.
3. Macaulay, A. A., Perfetti, D. C., & Levine, W. N. (2012). Anterior cruciate ligament graft choices. Sports health, 4(1), 63-68.
4. Petersen, W., Taheri, P., Forkel, P., & Zantop, T. (2014). Return to play following ACL reconstruction: a systematic review about strength deficits. Archives of orthopaedic and trauma surgery, 134, 1417-1428.
5. Randsborg, P. H., Cepeda, N., Adamec, D., Rodeo, S. A., Ranawat, A., & Pearle, A. D. (2022). Patient-reported outcome, return to sport, and revision rates 7-9 years after anterior cruciate ligament reconstruction: results from a cohort of 2042 patients. The American Journal of Sports Medicine, 50(2), 423-432.
