loris bertolacci

Sport, Health and Fitness

Is there a case for Decelerated ACL Rehabilitations?

Below is a link to an article on the recurrence of ACL injuries in the AFL.

Article on AFL Website “Recurring ACL injuries” May 6, 2014 Adam McNicol

“Eight of the injuries suffered in 2013 were cases in which players needed a second reconstruction after their initial graft failed. In three of those cases, a LARS graft had been used. Sparking concern is the fact that no more than four players experienced the failure of a knee ligament graft in one year during the previous decade”

Hamstring strains continue to be NO 1 injury in the AFL without fail, so one has to tread carefully about making too many conclusions after one years data.

But what interests me a lot is the concept of accelerated ACL rehabilitation. Because it is a fairly easy rehab program versus many others, in my view it is fraught with danger. So many athletes feel quite ok by 6 months and many young athletes simply cannot understand why they can’t twist, turn and play when they feel ok. The science behind grafts doesn’t gel with them. If it doesnt hurt and feels ok running “I should be ok!”

There are many studies appearing that look at the time to return of ACL rehab. and also recurrence rates and numbers vary. One interesting study given my interest now is often with the young athlete was a 2012 study American Journal of Sports Medicine: “Return to High School– and College-Level Football After Anterior Cruciate Ligament Reconstruction. Below is a summary of study:

” One hundred forty-seven players (including 68 high school and 26 collegiate athletes. Return to play rates for all high school and collegiate athletes were similar (63% and 69%, respectively). Based on player perception, 43% of the players were able to return to play at the same self-described performance level. Approximately 27% felt they did not perform at a level attained before their ACL tear, and 30% were unable to return to play at all. Fear of reinjury or further damage was cited by approximately 50% of the players who did not return to play. ”

But I thought an interesting excerpt from an abstract was made in the following study about return to play after ACL rehab.
International Orthopaedics February 2013,  Return to sport following anterior cruciate ligament reconstructionJulian Feller, Kate E. Webster

“Little is known about how to determine when it is safe to return to sport following ACL reconstruction or how to predict whether an athlete will be able to successfully return to sport. Finally, it needs to be recognised that return to sport following ACL reconstruction is associated with a risk of further injury and the development of osteoarthritis”

Yet time and time again on the internet or at conferences we get neat little packages of when to progress through a ACL rehab. and it reads so nicely given it is a ‘boxed in” with progressions such as ability to balance or ability to leg press or hop on the spot. Usually a neat powerpoint with each slide being a neat progression.

Given what is is appearing in studies of graft maturation and also the fact that players often take a minimum of 18 months to get some real form going one wonders if a more conservative approach is required. My subjective experience has been that athletes who  have progressed slowly and taken 12 months to rehab seem better off. I said seem! No data.

One study I read about graft revascularization said that it took 2 years to come back to normal.

Skeletal Radiology (2013) “By 2 years postoperatively, revascularization completion coincides with the homogeneously low signal intensity of the graft, closely resembling native ACL”

I know that some people can play at 6 to 9 months and are ok. And certainly avoiding high risk positions sometimes can be lucky or simply things just stick.

Another older study threw up the interesting notion of how well players perform at 18 months and this study suggests not as well which is my subjective experience.

Outcomes of Anterior Cruciate Ligament Injuries to Running Backs and Wide Receivers in the National Football League The American Journal of Sports Medicine, 2006
CONCLUSION
The present study found that approximately four fifths of NFL running backs and wide receivers who sustain ACL injuries return to an NFL game. The majority of returning players first compete in an NFL game 9 to 12 months after injury. On return to competition, running backs and wide receivers after ACL injury are approximately two thirds as productive as they were before injury. These players were selected as the focus of the study because running backs and wide receivers are the offensive skill positions with the highest frequency of injury,3 and components of their performance can be objectively measured.

And an even older study spoke about how one leg hops did not return to normal after 18 months. This is something I have often seen given lack of confidence when hoping. At one conference I went to recently a study had players hopping 3 hops the same as the good leg after 6 months. But the distances quoted were very poor so in my opinion meant little given there was doubt that the athlete has been tested maximally on the contraleteral leg. And so many footballers just hop so poorly anyway. I did a million hops myself and with athletes and have a good feeling for benchmarks for 3 hops. In my opinion these tests have to be maximal otherwise like a lot of testing is pretty useless data.

THIS STUDY BELOW TALKS ABOUT 2 YEARS TO GET BACK TO NORMAL WITH HOPS

J Athl Train. 2002 Strength, Functional Outcome, and Postural Stability After Anterior Cruciate Ligament Reconstruction

“After ACLR (mean = 18 ± 10 months), subjects did not have significant loss in bilateral or single-limb postural stability when assessed with a Biodex Stability System.Functional hop performance were not within normal limits when compared with the contralateral limb and a control group.  (as assessed with a single-leg hop-for-distance test) may not return to normal (±5%) for up to 2 years”

Exercise Physiologists and rehabilitation specialists often get very excited about getting a player back to play. But with the statistics seemingly showing that there are many issues associated after an ACL rehabilitation, I wanted to throw up a curve ball.

What would these statistics be if worldwide everyone for 10 years  slowed down and progressed slowly and played high level sport ( twisting/pivoting/accelerating etc) after a 14 or even 18  months ACL rehab?

I remember once at a conference an eminent doctor in the AFL saying that 3 weeks was enough for an AFL hamstring rehab because whilst there would be the odd clanger 4/5 weeks was just too long and hurt clubs on the field missing good players. Well years later clubs were forced to take longer with hammie rehabs and recurrence rates were lowered.

Tough one the ACL reco. But what worries me so often is the cavalier attitude of young athletes who have been reconstructed, the lack of understanding of what is happening and the excitement that many rehab professionals have in getting an athlete back on the pitch early. Plus the Internet!

 

 

 

 

 

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May 6, 2014 Posted by | Rehabilitation | Leave a comment