Jan 29, 2015The Best Approach?
It’s been almost 20 years since sports medicine professionals first tried an accelerated approach to rehabbing surgically repaired ACLs. The debate about its safety continues.
By R.J. Anderson
R.J. Anderson is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].
Thirty years ago, when an athlete tore an anterior cruciate ligament (ACL) the prognosis was pretty simple: His or her career was over. Fifteen years ago, most athletes with the same injury could hope to return to their sport in a year. These days, when an athlete tears an ACL, some doctors will clear them to rejoin the team in as few as eight weeks.
Advances in surgical techniques combined with adaptations in rehab protocols have produced some amazing comebacks. Basketball players who suffer an ACL injury during the summer are ready for practice in November. Soccer athletes who go down with an ACL in a preseason game are rejoining their teams for postseason competition.
However, as some sports medicine professionals continue to push the envelope on athletes returning to play, others wonder about the wisdom of this trend. Are there drawbacks to athletes resuming competition so soon after surgery? Has ACL rehab become too accelerated?
There are no clear-cut answers. With little clinical data available to detail the short- and long-term consequences of ACL rehab, identifying when an ACL graft is ready to absorb the pounding of competitive athletics is really just an orthopedic surgeon’s best guess.
“There aren’t great randomized controlled trials that say, ‘Aggressive is great’ or ‘Conservative is great,'” says James Oñate, PhD, ATC, Assistant Professor in the Graduate Athletic Training Program and Director of the Sports Medicine Research Laboratory at Old Dominion University, who defines an accelerated program as taking three months or less and a conservative approach as taking nine months or longer. “There is, however, a lot of personal and anecdotal information out there.”
Pros & Cons
Donald Shelbourne, MD, Orthopedic Surgeon at the Shelbourne Clinic at Methodist Hospital in Indianapolis, is widely credited with pioneering some of the most accelerated rehabs following ACL reconstruction. Though his athletes are back competing in very short periods of time after surgery, Shelbourne doesn’t want his approach labeled as “aggressive.”
“Aggressive is a misnomer,” says Shelbourne. “We’re not trying to be aggressive, we’re trying to be restorative and get the patient’s motion back as quickly as possible. Rehab can take a long time when people go to therapy with restricted motion, poor strength, or a swollen knee.
“Our goal is for our athletes to have two knees that are the same as they were before the injury–how long that takes doesn’t matter,” adds Shelbourne. “If you’re an athlete and I say you can’t play sports for six months, what’s that based on? What happens in five months, three weeks and six days that makes it so you can’t play sports, but the next morning you can?”
Shelbourne’s clinic has been using an accelerated approach for 17 years on over 5,000 athletes. “Since 1989 we’ve allowed people to go on their own timetable. We’ve documented every patient and haven’t found any correlation between returning in any certain time period and having problems,” says Shelbourne. “When you deal with athletes, you can’t use generalities and vague guidelines. People who recommend a certain time period are not basing their recommendations on facts–certainly not any clinical data.”
Once motion and strength are symmetrical for each leg and there’s no pain or swelling, Shelbourne believes the athlete is ready to return to practice with his or her team. “Everybody makes it way too complicated,” he says. “An ACL rehab program should have a simple goal of getting motion and strength back to normal as soon as possible. We shouldn’t have all of these theoretical rules. There’s no reason to restrict motion and there’s no reason to restrict strength if there isn’t any pain or swelling.”
While Shelbourne preaches simplicity, other surgeons aren’t so sure. Because the biology of ACL repairs is largely unknown, many sports medicine professionals prefer a more conservative timetable before returning an athlete to competition.
“I don’t think two months is enough of a trial,” says Russell Zelko, MD, Orthopedic Consultant to Cornell University’s athletic program. “I think it takes far longer to strengthen that ligament–I would say six months minimum. Rehab only addresses the structural integrity of the graft to a certain degree. To me, it’s more a matter of time, similar to how a fracture heals.
“I don’t think a return-to-play decision should be based on the mere fact that you look fully rehabilitated,” Zelko continues. “It needs to be based on other factors, like the biology of the repair and how long it takes for the ACL to revitalize. When you do an ACL reconstruction using other tissue, that tissue essentially dies and has to revascularize. The leg may be functionally rehabilitated, but the graft itself may not be ready to take the stress of going back to participation after only a couple of months.”
Shelbourne counters that following a standard six-month time frame before releasing an athlete is based on arbitrary criteria. “In our research, we’ve documented the incidence of athletes having a re-injury or injuring an opposite knee, and we’ve found there’s no time period that indicates a higher rate of incidence. So why wait?” he asks. “We’ve never had a patient break their graft because they went back too soon. Once you’re symmetric, you have the same chance of getting hurt whether it’s two, four, six, or 10 months post-surgery. Give the athlete a goal of being symmetric. If they reach it, let them go back and play.
“We published a paper on this 16 years ago, but a lot of people still say, ‘Patients who go back before six months are at risk of breaking their graft,'” Shelbourne adds. “It’s like the old adage that you shouldn’t go swimming until an hour after you’ve had lunch. Has anybody ever documented that?”
Luga Podesta, MD, Physical Medicine and Rehabilitation Specialist at Ventura Orthopedics, Head Team Physician for the Los Angeles Avengers of the Arena Football League, and a consultant to the Los Angeles Dodgers, feels there are psychological factors that need to be taken into account before releasing an athlete to return to play after an ACL surgery, and thus is not a proponent of accelerated rehabs. If there is a swelling setback because of being a little too aggressive and returning to competition too soon, Podesta feels it can destroy the athlete’s confidence.
“That’s a huge factor for all my patients, including my professional athletes,” says Podesta. “As much as they want to push and get back, it’s often tough to have them back playing at a high level, even at six months, because they’re reluctant to try certain types of cuts and movements.
“They’re still in an injured mindset and they’re constantly thinking about their knee,” Podesta adds. “And in trying to protect that knee, they open themselves up for other types of injuries.”
For ACL reconstruction surgeries, Shelbourne uses the contra lateral patellar tendon technique, in which the tendon graft is harvested from the non-injured knee, and his rehab protocols address the donor and the ACL graft sites separately. Despite having to follow a different rehab program for each knee, Shelbourne’s patients often move through the process quickly, with some athletes returning to practice two months post-surgery. For Shelbourne, returning a patient’s injured knee to pre-injury ROM levels as soon as possible is the number one goal during the early stages of rehab and the key to a successful outcome.
In the days leading up to surgery, Shelbourne’s physical therapists work with each patient to make sure they can bend their knee at least 140 degrees. After the surgery, patients stay in the hospital overnight then are sent home to spend the next five days in bed with their knee wrapped in a cold compression cast and elevated over their heart while using a Continuous Passive Motion (CPM) device to extend and flex the knee.
“If you can prevent swelling and hemarthrosis and not lose motion or allow any pain to occur, then the patient is going to recover more quickly,” says Shelbourne. “If a patient is allowed to walk around immediately after surgery, they may be lucky to have 90 degrees of flexion after one week. They’ll probably have a lot of swelling, walk with a limp, and can’t possibly envision going back to sports in six weeks.”
After spending a week off their feet, Shelbourne’s patients begin traditional knee flexibility and strengthening exercises. “If someone wants to get back to sports quickly, their biggest challenge is regaining the strength in the grafted leg where the patellar tendon was taken from,” says Shelbourne. “If the patient is really motivated, they can get that strength back to a symmetric level within six weeks. Of course, if they get swelling or lose motion during that time, we back them off.”
Jeff Pierce, ATC, Head Athletic Trainer at Villanova University, says that his approach to ACL rehabs has become more accelerated over the past five years. This shift intensified even more after rehabbing one of his athletes who was operated on by James Andrews, MD, Co-Founder of the Alabama Sports Medicine and Orthopaedic Center in Birmingham, Ala.
“Before we worked with Dr. Andrews, we thought we were somewhat aggressive in our approach,” says Pierce. “But after seeing what he does, we realized how much more aggressive we could get. Dr. Andrews and his group are not afraid to work through a patient’s discomfort. For instance, the first day post-surgery they have patients in the clinic bending their knee to 90 degrees–that blew me away.
“The goal is for the athlete to not lose any strength or motion, so we work on regaining motion and initiate the strength building phase right away,” continues Pierce. “The athletes also do straight-leg raises and use Russian Stimulation to electrically activate the quad. They perform hamstring curls within the limitations of the range of motion to keep the patella moving so it doesn’t adhere. To help control swelling, when the athletes aren’t working out they wear temperature-controlled compression wraps.”
During the second week, Pierce says protocol typically calls for standing weight shifts and mini squats to 30 degrees. At the two-week mark, if the athlete is pain-free and doesn’t have any swelling in the knee, Pierce adds weight to the exercises–typically one to two pounds at first, and progresses from there. From weeks four to seven, athletes begin to do pool work, step-ups, closed-chain activities, and leg presses using minimal weight.
Injured athletes attend rehab sessions twice a day for about an hour and a half per session, depending on how the knee responds. “If there is an increase in swelling, we back off,” Pierce says. “But that’s not something we’ve seen yet with athletes who have followed this protocol.”
Bill Knowles, ATC, CSCS, Athletic Trainer and Director of iSPORT TRAINING at the Vermont Orthopaedic Clinic in Rutland, Vt., feels a key to an accelerated process is introducing balance and proprioception work, closed chain exercises, and functional training during the first eight weeks post surgery. “To me, the goal of an accelerated rehab program should be to increase the preparation period prior to return to sport,” says Knowles, who calls this the reconditioning period.
“I try to run progressive programs that give the athlete a longer period of time–even if it’s a month or two–to train for competition. It allows them to slowly work up to training at a higher level, which better prepares them and decreases the risk of injury because they spend more time practicing and conditioning for their sport.
“You can do all the sport-specific training you want, but you won’t know how well you’ve progressed until you start working in a high intensity environment using unplanned movements,” adds Knowles, who works with high school, college, professional, and Olympic athletes. “You need a fairly significant volume of that kind of work to best prepare your athlete for performance and to decrease the risk of re-injury, which can mean two, four, or six weeks of practice before the first game. It really depends on the individual and the severity of their injury.”
For Shelbourne, allowing a patient to return to play is based on having both legs symmetric in ROM and strength at pre-injury levels. However, even though he may clear athletes to return to their teams, they do not practice every day, and for the first four months, Shelbourne tells them to expect some swelling and loss of motion from time to time. To build up their strength and limit swelling, Shelbourne restricts an athlete’s participation to one day on, one day off, then progresses them to two days on and one day off.
“It’s like spring training for baseball players–it takes a while before you’re really ready to compete at the same level as before you got hurt,” says Shelbourne. “But you are able to do it safely.”
Pierce first used Andrews’s rehab protocols with Curtis Sumpter, a star forward on Villanova’s men’s basketball team. Sumpter re-ruptured his left ACL during a practice on Oct. 19, 2005, six months after the initial tear during an NCAA Tournament game the previous March.
After the first injury, Sumpter, then a junior and a highly regarded NBA prospect, underwent allograft reconstruction surgery. “The first time around, Curtis’s body just didn’t accept the allograft and the tendon never vascularized,” says Pierce. “For Curtis’s second surgery, we went to see Dr. Andrews [who did not perform the initial surgery]. He said the rupture was an unexplainable complication that can happen with an allograft procedure and also he told us we couldn’t have done anything during rehab that would have prevented it.”
In November 2005, Andrews performed an autograft procedure on Sumpter’s knee. Immediately after the surgery, Andrews and his staff began the aggressive rehab.
After following Andrews’s rehab protocols for three months, Sumpter was deemed physically able to rejoin his teammates during their February postseason run. His knee was considered healed, and Andrews felt there was little risk of re-injury. However, Sumpter lacked explosiveness and had a very difficult choice to make: join his teammates in a reduced role and play in the NCAA Tournament, thus forfeiting his final year of eligibility, or take a medical redshirt and return stronger and more confident next season.
“We explained to Curtis and his family that he had not played since October and the likelihood of him picking up where he left off would be very slim,” says Pierce. “We also told him what to expect if he tried to come back right away–possibly developing patella tendonitis, fusions in the knee, swelling that would allow him to be on the floor one day, then have to sit out for the next two. We told him it would be a constant battle all the way through.”
After a few practices and much deliberation, Sumpter realized that he wasn’t ready to compete at an elite level and he decided not to return for the 2006 postseason. “There’s no question he made the right decision,” Pierce says. “At that point, we slowed things down and started working toward getting him ready for the next season.”
After a spring and summer of ramping up his workouts, Sumpter returned for the 2006-07 season in great shape and with the confidence he had before the initial injury. He played over 30 minutes a game, averaged 17.4 points per contest, and led the Wildcats to a berth in the NCAA Tournament.
No Cookie Cutters
According to Oñate, there are no easy solutions to the aggressive vs. conservative rehab debate. “I sit on the fence on this issue because I don’t think there is a right or wrong answer for every athlete,” he says. “There’s not a lot of evidence heavily weighted toward one side or the other. It’s a boxing match, and both sides are throwing good punches.”
Oñate feels there are instances that call for an aggressive plan. In those cases, he stresses a need for open lines of communication between the surgeon, athlete, athletic trainer, physical therapist, and anyone else involved in the process such as strength coaches, parents, and sport coaches. “There should be a game plan among all of them,” he says. “That plan starts with assessing the patient’s goals and adjusting the rehab program accordingly.”
Knowles agrees that the key is learning how to customize a plan for each athlete. With so much new information available, it’s up to the athletic trainer and orthopedic surgeon to design a protocol that fits the patient’s needs. “No matter which program you follow, you must have a strong strength and conditioning background and know how to manage an athlete,” Knowles says.
Oñate stresses it’s important to understand that ACL rehab is a process, not a program. “And a process should constantly evolve,” he says. “It can’t be one size fits all.”
SIDEBAR: One-Year Rule
Brian Roberts, MS, ATC, Director of the Center for Medicine and Sport in Chino, Calif., says in the last five years, he’s encountered an increase in high school athletes–especially girls’ soccer players–re-rupturing ACL grafts. And he blames the re-injury surge on overzealous parents and coaches pushing young, elite-level athletes to return to play before they are physically and mentally ready.
“Part of the reason why the incidence rate has risen is the athletes don’t appreciate the amount of time it takes for a graft to vascularize and heal the way it’s supposed to,” says Roberts, who works with high school, college, and professional athletes. “And unfortunately, in this age of HMOs, a lot of the athletes aren’t getting great post-op rehab. Kids are being discharged too early, they’re not following up with an athletic trainer, and in many cases, they’re not getting the functional drills and assessment tools they need to return at full strength.
“Another problem is that we don’t really have clear criteria that indicates when a graft is ready to be stressed,” he continues. “Coaches and parents see that the kids are able to run, and they assume the natural progression is for them to start playing again. In many cases, that’s just not true.”
As a result, Roberts began telling his patients that the return-to-play time after an ACL tear is one year post-surgery. Doing so, he says, has helped decrease the re-rupture rate.
“In this profession, you can’t be afraid to be a bad guy when holding somebody out longer than they’d like,” says Roberts. “I get calls from coaches all the time asking when a kid can return. So I ask the coach, ‘Are you prepared to assume the responsibility for that player if they return too early and hurt themselves?'”
I agree that there should not be a “cookie cutter” protocol when dealing with ACL repairs. Each athlete should be treated utilizing information based on that athlete – not someone’s timetable. That being said, symmetrical strength and ROM without pain/swelling seem to be critical in any scenario. Remember some of the basics – if there is pain and swelling, no matter how fast the ATC, MD or PT wants to get the athlete back, it just won’t happen. Lastly, let’s not forget the psychological impact of the injury. If excelling at any sport is 90% mental and 10% physical – why isn’t the rehab approached that way? What the mind can conceive the body can achieve – even in rehab. -Yvette Appleby, VATL, ATC