ACL INJURIES – FROM TEARS (BOTH KINDS) TO BACK ON THE FIELD – HOW TO DO IT RIGHT
Author: Rick Groffsky (an unqualified but far too experienced parent)
Anyone reading this article should do so with the clear understanding that it is being written by someone who is neither doctor, physical therapist nor athletic trainer. I am a lawyer, which standing alone renders me completely unqualified to offer advice to anyone on the topic of ACL injuries. What gives me the idea that I have something to offer is the fact that I am the father of two soccer-playing daughters who have had the pleasure of sustaining 3 ACL tears during the past three years. That unfortunate fact, along with spending a lot of time reading journals, talking to experts, and then speaking with other parents whose kids have the same injury, has led me to realize that most parents and players have little if any idea as to how to approach this type of injury, and often enter the process of surgery and rehab with little real idea about how either should be done. Through our experiences I have learned that doing both of those things right is absolutely critical to a safe and speedy return to play, and perhaps more importantly can lower the risks of injuries in the future.
Let’s begin with an important but unassailable premise: to obtain the best short and long term result from this injury, it is not enough to just have a good surgeon do a good repair, or a good PT do a good job getting range of motion and strength to return, or a good trainer to retool the players body to get them ready to get back on the field of play. While luck and genetics may allow for a decent result with none of the above, experience and common sense dictate that all three must happen in order to maximize the likelihood of a good outcome.
Let’s begin with the surgeon and the surgery. We all have friends who know a surgeon who did a great job with someone’s broken wrist or sprained ankle. While it can seem reassuring to go to a doctor based upon this type of recommendation, when looking for someone to reconstruct a torn ACL there are much more important issues to be addressed. First, find out how much of their practice is ACL reconstruction, or how many they do in a given year. If the answer is not too much or not too many, say thank you and goodbye no matter what else you have heard about them. They may say that this is an easy surgery to do, but I assure you that after seeing how many of these have turned out it is not such an easy one to do right.
The second thing you should find out is how they do the repair. Depending on age, level of activity desired to return to and prior injuries to the knee there are multiple options for the material and technique to be used to replace the torn ( and now useless- the original cannot be repaired ) ACL. Hamstring, quadriceps and patellar tendon autografts (tissue taken from your own body) can all be used, as can tendon allografts, which are taken from cadavers. If one were to poll a group of experienced orthopedic surgeons you would find that there is clearly a difference of opinion between them as to whether there is one best option for a quick and safe return to play, and more importantly getting the best long term result. I have a definite opinion about this based upon my experience and readings, but ultimately you to decide with your doctor (and perhaps by doing your own research) which is right for you. I would caution, however, that the answer you get to that question may be more a function of the surgeon’s comfort with a particular type of procedure than it is their objective view of the currently available data.
PHYSICAL THERAPY (PT)
In the early 1990’s, it was realized almost by accident that older approaches to the rehabilitation of an ACL reconstruction were not only not helpful, but in fact deleterious to the recovery of patients. Recognized at that time was the fact that non-compliant patients who did things quicker than their surgeons had recommended were getting better results, and thus a greatly more accelerated rehabilitation program was born. This regimen has been modified to move even more quickly in recent years, leading to a program that is dramatically different than the one used by therapists and surgeons 20 years ago.
When I tore my ACL 20+ years ago, the first surgeon I spoke with talked about my upcoming year long rehab program, with a long period of non-weight bearing to be followed by a very slow return to activities. This would involve running by 6 months, and a return to sports at the one year anniversary of my surgery. Fortunately for me, the second opinion I got was much more enlightened, and pushed me in the direction of what was then the fairly new idea of accelerated rehabilitation. Running by 6-8 weeks and back to skiing at 4-5 months sounded much better to me, and reading the medical papers which laid the foundation for this approach reassured me that it was a safe way to go.
It is not quite fair to say that the benefits of a well done surgery can be ruined by lousy rehabilitation, but there is no doubt that the timing and safety of an athlete’s return to play is greatly influenced by how their physical therapy is performed. The initial goal of that therapy is to achieve full extension of the leg and near normal flexion as soon as possible after the surgery. This will lay the foundation for getting the patient to weight bear, walk normally and run much sooner than you might realize it can be done. Depending on the type of ACL reconstruction that is performed, weight bearing can begin immediately, crutches disposed of as soon as pain allows for it ( days, not weeks ), and running in a safe environment, i.e. on a treadmill supervised by PT staff, by four weeks after surgery. Yep, four weeks.
It is important to recognize that a proper rehabilitation program is primarily goal based, and not simply a function of time passed since surgery. Gone should be the days when kids get released to play simply based upon being 4 or 6 or 8 months post-op, replaced instead by looking and pushing for milestones in strength and coordination that allow for a safe progression to additional, more demanding activities. Time does, however, play a role in the decision, and one of the real differences between the types of surgical reconstructions is the speed with which one can approach the rehabilitation process. It seems clear that patellar tendon autografts permit a faster progression through the steps involved in rehab, such that if the player is properly managed and their rehab without complication they can be returned to play, SAFELY, by 4-5 months. For other types of surgeries, the nature of material used and the way it is implanted may dictate a slower progression through rehab, and therefor a longer timeframe to return to play.
It is to state the obvious that you, your surgeon and your therapist should decide together the best approach to the physical therapy process. However, if for example your child has a patellar tendon autograft and is told that the process to get back on the field will be 6 or 8 months long, make sure you ask them why, and then go get a second opinion from someone who can explain to you why it may not have to be so.
ATHLETIC TRAINING (AT)
For many people the process from injury to return to play consists of only two steps – surgery, and physical therapy. Having personally experienced the recovery process that way, I am convinced that there is a better one, one which at a certain point in time ends PT and begins another phase of the rehabilitation program, athletic training/strength and conditioning. Physical therapists and athletic trainers will tell you that while their training and orientation may overlap, their focus, at least in this context, is very different. The important progressions that are made through the physical therapy regimen at some point reach a point where they cannot push the athlete in a way that they need to be pushed before playing again. Having seen both of my kids return to play within the 4-5 month window, one without AT, it is clear that leaving PT and beginning a more demanding training program at 2 ½ -3 months post op is both physically and mentally beneficial to the player.
Strange as it may sound, neither of my kids had much of a fear of going back to play. Some of this is likely just because they were teenagers and not fearful adults, but some of it also was a confidence that comes from knowing that they were ready. The role that AT plays in the latter cannot be over –emphasized, as there is a huge gain in performance and in turn confidence that comes from the strength, speed and plyometric training that AT’s are best at delivering.
As with the coordination of care between the surgeon and the physical therapist, the transition from PT to AT should be discussed by everyone involved. A good therapist will tell you when you are ready to better be served by an athletic trainer, and together they can decide how quickly you can safely move forward from there.
I believe that if asked our PT and AT, who we think are as good as they get in their respective fields, would tell you that they learned something from each other during our last go around with ACL rehab. After seeing what the AT could do in terms of facilities and training, the PT told us that our daughter had “outgrown” PT, and that she would best be served by moving on to that other environment. This was not something that he had regularly planned for or recommended to his PT patients who wanted to return to high level sports, but I think it may be now. Similarly, the AT was used to working with surgeons and PT people who did not move the rehab process forward as fast as it can be done, so when he started training my daughter at 2 ½ months, he did not believe that she was ready to do the things that she ultimately was able to do. Only after talking to our PT, and seeing what had been accomplished within those first 2 ½ months, did he buy into the idea that if the foundation is laid at surgery and PT a safe, strong return to play can happen in that 4-5 month timeframe.
Like most things in medicine, and in life for that matter, the approach to ACL injuries has changed quite a bit in the last two decades. While an ACL tear can initially be devastating to the athlete ( and their family ), the changes in treatment available today allow for a much faster physical recovery from the reconstructive surgery, and with it a much improved mindset for the player. You can imagine how much better it sounds to be told that you will be off 4-5 months rather than 6-8 months or more, and the knowledge that you can return to play in that shortened timeframe provides great motivation to those affected by the injury.
This article is written to provide to players and their families a good way to approach the process from ACL injury to playing sports at a high level again. I understand that not all players/parents will be comfortable with moving ahead as quickly as I have suggested it can be done, nor will they all have the insurance or financial resources to see the process through. Those constraints are understandable and real. Saying that it can’t be done in the way I’ve outlined is neither.