ACLR Rehab and Return to Sport Criteria

ACL Rehab & Return to Sport Criteria

This blog entry is based on an assignment on ACL return to sport criteria from my Masters course last year (thanks must go to my peers, especially Kylie Baldwin and Jennifer Callaghan) as well as information from APA Sports Physiotherapist Randall Cooper and his recent presentation on ACL Rehab Criteria. 

Randall presented a 5 stage criteria driven rehab protocol including the Melbourne Sports Score to assist in progressing rehab following ACL reconstruction and knowing when a patient is safe and ready to return to sport.  I’ll discuss each stage briefly with my opinions and variations, but you can find the full documents describing each stage on Randall’s blog here: www.swollenknee.me Thanks again to Randall for being so generous with sharing this information.

I’d love to hear any variations or additional criteria that you use, or recommend using.

Stage 1: Immediate Post Op – Recovery from Surgery

Aims	Treatment Options	Criteria to Exit Stage 1
Reduce pain	Ice	Full PROM Knee Extension
Reduce swelling	Elevation	PROM Knee Flexion 100deg
Safe mobilisation	Pain relief	Zero to mild amount of swelling
	Adequate rest	Quads lag 0-5deg
	Braces, crutches as needed

Goals of this first stage are to regain knee extension, settle the swelling and activate the quads.

Stage 2: Strength and Neuromuscular Control

Aims	Rehab	Criteria to Exit Stage 2
Regain single leg balance	Massage	Full PROM Knee Extension
Regain muscle strength	Joint mobilisations	125deg+ PROM Knee Flexion
Good single leg squat technique and LL alignment	Quads (contracted with hamstrings) strengthening – IRQ, mini squats, squats, mini lunges, lunges, leg press double, leg press single	No swelling or effusion
	Hamstring Strengthening – bridging, deadlifts, prone or seated hamstring curls, hamstring flicks	5 single leg squats with ‘good’ alignment based on Crossley et al 2011
	Calf Strengthening – calf raises	No. single leg bridges >85% of other leg
	Abdominal/Core strengthening – plank, side plank, bridge and leg lift, leg lifts, leg slides/extensions, crunches	No. single leg calf raises >85% of other leg
	Ice/elevation as needed – mostly after exercise sessions	Timed side bridge/plank >85% of other side
	Cross training UL	1RM single leg press = 1.5xbody weight
	Ex bike, rowing for cardio	Single leg balance eyes open=43sec, eyes closed=9sec

 

So here’s where we start to debate the numbers.  Are 5 single leg squats enough to prove you have sufficient neuromuscular control to move to Stage 3?  If your athlete is returning to a running sport, then they will eventually need to squat/hop/jump a lot more than 5 times.  Crossley’s test is also based on patellofemoral pain, so we need to decide whether this can be extrapolated to the ACLR population – time for another RCT.  Another question is whether 1.5x body weight is too much (or too little) as a Strength measure in Stage 2.  We also need to remember when comparing % of one leg to another that the so called ‘good’ leg may have previously been injured and thus the comparison is not entirely valid. 

Stage 3: Running, Agility and Landing

Aim	Rehab	Criteria to Exit Stage 3
‘excellent’ score on jump-rebound task	Shuttle runs	Single Leg Hop test >90% of other leg
Progressive agility training	Ladder drills	Triple Cross Over Hop Test >90% of other leg
Regain full Strength and Balance	Slalom running/cutting drills	Landing Error Scoring System (LESS) “Excellent” Score
	Jumping – double leg, floor, box, perturbations	1RM Single leg press 1.8x body weight
	Hopping – single leg, floor, box, change of direction	Star Excursion Balance Test (SEBT) >95% of other leg in Anterior, Posterolateral and Posteromedial directions

The patient must have met the criteria of Stage 1 and 2 before entering this Stage of rehab.  I can’t justify starting a patient on a return to running program if they only do 5 single leg squats.  My general outcome measures for returning to running are 30 single leg squats, 30 single leg calf raises and 30 single leg bridges as a minimum.  I’d be interested to hear what your criteria are!?

Before testing the exit criteria for Stage 3, it is also recommended that the patient have no side to side difference in the single leg bridge test, single leg calf raise test and side bridge endurance test, while maintaining FROM in the knee, no swelling and ‘good’ single leg squats.  

Stage 4:Return to Sport

Aim	Rehab	Criteria to Return to Sport (Melbourne Sports Score)
Score >95 on Melbourne RTS Score	Sports Specific Drills/Skills Strength and Conditioning Program	Physical Examination (/25) Effusion Stability/Laxity Flexion ROM Extension ROM
Athlete is confident, comfortable and eager to RTS	Plyometrics	Functional Tests (/50) SEBT Single Hop for distance Triple Hop Jump/Land ability – modified LESS score SL Squats
A continued ACL injury prevention program is discussed and implemented.	PEP or FIFA 11 prevention program (stage 5)	IKDC/Subjective Qs (/25)

 

Should we be including more tests?

Are these criteria enough to justify safe RTS? Pilot data suggests that a score of 95/100 indicates a greater chance of returning to pre-injury sports.  Further research is also needed to see whether these athletes (scoring >95/100) also have a lower re-injury rate.

Stage 5: Prevention

There are a number of preventative programs already available, including FIFA 11 and PEP program.  You can find these online easily.

Conservative Management

Apart from the acute post op management, conservatively management ACL injuries should follow a similar set of rehab and return to sport criteria.