If you are an athlete with an ACL injury or if you are the parent of a student athlete with an ACL injury, you will likely have many questions regarding how the injury should be managed before, during and after surgery.
In our prior series with expert ACL surgeons we discussed which athletes should consider ACL surgery . Whether or not you choose to proceed with surgery, your Physical Therapist and Athletic Trainers will be essential to guiding you properly.
This will be the second in our series of posts where Athletic Trainers and Physical Therapy experts who work with ACL injured athletes each and everyday answer your most common ACL questions. In our first post, we discussed how to choose the Orthopedic Surgeon who will perform your ACL surgery.
In this post we will discuss the role of the Physical Therapist and Athletic Trainer in treating the athlete BEFORE surgery. How an ACL injured athlete is managed from the time of the injury until the return to sports is critical to:
- minimize the risk of complications after surgery,
- improve the chances of a successful return to sports and
- minimize the risks of a second ACL injury.
The Role of Physical Therapy Before ACL Surgery
Prehabilitation prior to surgery is extremely important on many levels. In my opinion, the 3 most important physical goals prior to ACL reconstructions: 1) minimize pain & swelling; 2) restore knee range of motion, especially extension; 3) restore quadriceps muscle activation / neuromuscular control. The importance of restoring knee extension range of motion and quadriceps strength should not be overlooked. Loss of 3-5 degrees of knee extension motion compared to the uninjured side (including hyper-extension) has been shown to be associated with decreased functional outcomes.(Sehlbourne & Grey, 2009). Similarly, a 20% deficit in strength before ACL reconstruction has also been associated with decreased functional outcomes.(Eitzen et al, 2009). The risk of developing osteoarthritis is also higher in those with asymmetrical knee extension motion and strength.(Shelbourne & Grey, 2009; Roe et al, 2005)
In addition to these physical goals, there are also important psychological goals that can be addressed during the prehabilitation process. The recovery and rehabilitation process following ACL reconstruction is long and difficult, thus this is a good time to begin to mentally prepare the patient for the process. In addition, you can educate the patient on the time and effort that will be required to return to sport at an even higher level than prior to their injury. This is an important step where you match the patient’s expectations to the time and effort that will be needed. During this process you may also develop the rapport and trust of the patient that is needed.
It’s a must if you want a jump on the rehab on the other side of surgery. Studies back up the benefit of it – athletes not doing pre-hab take longer to return to sport. The goal of pre-hab is to get both legs as similar as possible to each other and to pre-injury status in terms of range of motion, swelling, and strength. In addition, it allows the patient to normalize walking and center of balance again before having to re-learn it all over again after surgery…you are giving yourself a better starting point. It also allows the patient and PT to get to know each other, build a positive rapport, and understand each other prior to surgery which is invaluable and makes the post–surgical rehab smoother and more effective.
There has been some debate on the whether or not there is a role for the PT/AT prior to surgery. Although the studies may not be completely clear, there several “key roles” to for the PT/AT prior to surgery that do have a significant impact on the patient and outcome. These can be categorized in three
1. Maximizing pre-op range of motion, inflammation control and strength. Those who have better range of motion, less swelling and improved quad control pre-operatively tend to regain it quicker post operatively.
2. Patient education. This not only helps to help expedite their recovery but can also help to elevate a lot of anxiety. This is a critical part and can include lots of things including:
a. Education on the process – educate the patient and care giver on what to expect after surgery. Educating on proper positioning in bed, use of CPM (if being prescribed) & post-operative instructions (icing, range of motion, quad sets) that can be performed the day after surgery prior to seeing the PT for the 1st post op session.
b. Education on use of assistive device – if they are going to be using crutches, setting them up with proper fitting crutches and how to ambulate with PWB (partial weight bearing) or WBAT (weight bearing as tolerated) and how to navigate stairs or curbs safely.
c. Educate on what to expect in their first PT visit when they come in.
3. Reassure the patient. It is vital for the PT/ATC to instil confidence in the patient in whomever is performing the surgery. Encouraging them and reassuring them will not eliminate fear and anxiety but it will decrease it.
All that said, there is the unspoken psychological aspect and positive influence this also has on the patient. If there is one thing that is often undervalued in ACLR, it is the impact that psychology has on the patient and outcome. Considering, there is a positive psychological impact to the visit. The PT/ATC should never undervalue the impact they will have on this pre or post-surgery.
Optimizing knee range of motion and function pre-surgery are important for a successful post-surgical outcome. For most patients, surgery following an ACL tear often occurs a month after injury to allow swelling to decrease. However, during this time, patients can develop significant muscle atrophy, range of motion deficits and compensatory movement patterns. Physical therapists are trained to reduce – if not eliminate – these problems pre-surgery. Additionally, an important but overlooked role of a PT is to counsel patients on the expected post-surgical rehabilitation course, general milestones and expected outcomes. Unfortunately, ACL reconstruction does not guarantee return to pre-injury activity – there is a higher-than-desired risk of re-rupture or ACL tear in the uninvolved knee even within the first 2 years post-surgery. PTs must help patients understand early that compliance with physician and therapist recommendations are key to a successful recovery.
Anja Goebel : @ACL_not_again :
It’s quite simple. The stronger you go into surgery, the better you come out. It is important to restore range of motion (especially extension), neuromuscular control and strength before heading to the operating room. The body has a recall system of its own, that’s separate from our cognitive memory. Movement patterns/muscle memory established before surgery will be picked up quicker in the post-op phase. The patient should head into surgery with a knee that feels as “normal” as possible. In addition to the physical benefits, prior to surgery is a great time for the PT/AT to develop rapport with the patient. It is an important time to establish trust and to ensure the patient that you care. I believe that ATs have a head start in this department because they already worked with the individual prior to them transitioning from student athlete to patient. PTs/ATs can reduce a lot of anxiety by explaining what’s to come and by answering patient questions that arise in between physician visits.
PT/AT plays a critical role in pre op care. Before surgery, your PT/AT is responsible for helping you regain ROM, increase strength, decrease edema, and for educating the athlete on the post op protocol. Its good for the athletes to know what to expect and to prepare them for the first few days after surgery. This is also a time for the provider to build a good rapport with the athlete. I find that the more channels I can open for my athletes and patients to communicate with me the better the outcomes.
My thoughts: As I tell the athletes I see each and everyday. Recovery from an ACL injury is just as much an emotional and psychological effort as it is a physical effort. It was very enlightening to read how important our experts universally felt that the pre-surgery interactions with their patients is critical to lay the groundwork for establishing a trusting relationship at the onset of what will be a long road to recovery.
Anja Goebel : @ACL_not_again