I’ve discussed some of the issues with return to play after ACL reconstructions recently. Fear of reinjury and other psychological issues can be huge barriers for many athletes. Determining when an athlete is physically capable of not only playing, but also playing at her preinjury level, can be very difficult.
Despite these challenges, we should still aim to do everything we can to get athletes and active individuals back to sports and exercise after ACL injuries. Just because some studies show that fewer than half of athletes return to play at preinjury levels by 12 months after surgery doesn’t mean that we can’t try strategies to improve these return to play rates.
Prehab for ACL reconstruction
A study published in the September 2013 issue of the American Journal of Sports Medicine looks at the effects of a six-week exercise program performed by patients before their ACL surgeries. Shahril R. Shaarani and others compared results of strength tests, functional performance tests, muscle biopsies, and patient outcome scores at 12 weeks after surgery between patients who completed their prehabilitation programs and those who didn’t.
What is prehabilitation?
As defined by the authors, prehabilitation is the process of “preparing an individual to withstand a stressful event through enhancement of functional capacity.” In terms of outcomes after ACL reconstruction, we usually refer to work with a physical therapist before surgery to improve quadriceps strength and lower extremity function as prehab.
In this study, the authors had patients in the prehab group perform an exercise program four days per week for six weeks. For two days, the patients performed exercises with physical therapists in the gyms with weights and machines. On the other two days, patients performed exercises at home with Thera-Bands.
They performed exercises for three sets of 12 repetitions. The patients increased the weights 10 to 15% each week. They performed proprioception training on wobble cushions.
Did prehab improve recovery from ACL surgery?
Compared to the group that skipped prehab, the patient who performed the exercise programs before surgery had the following outcome gains:
• Only the exercise group showed significant increases on the Modified Cincinnati Knee Rating System scores compared to baseline scores at 12 weeks after surgery. The outcome scores in the exercise group were significantly higher than the group that did not undergo prehab.
• The exercise group did much better on the single-leg hop test 12 weeks postoperatively than the control group did. This test is widely thought to be one of the best functional tests of lower extremity strength.
• Mean return to sports for the exercise group was 34.18 weeks, compared to 42.5 weeks in the control group.
Thoughts of an ACL expert
I asked Julie Eibensteiner, PT, DPT, CSCS, a physical therapist in Minneapolis, Minnesota who focuses her practice almost exclusively on athletes rehabbing from ACL injuries and surgeries. “As a clinician, the benefits of participating in prehab prior to ACL reconstructive surgery is very apparent and is an important tool in the recovery process for every injured athlete,” she explained.
“Patients who have normalized swelling, range of motion, and neuromuscular control of the quads prior to surgery tend to do significantly better on the other side of surgery,” Eibensteiner observed. “In addition, the psychological benefit of being able to develop a positive rapport between patient and physical therapist and building good rehab habits is priceless.”
What can athletes take away about prehab?
There is clearly much more we need to learn about prehab programs prior to ACL reconstruction. Do these benefits still exist 12 months after surgery? Do they increase even more one year later? Which exercises are most important? Can a two- or four- week program be equally effective? Can entire home-based exercise programs benefit patients?
Clearly this type of program should help most athletes preparing for ACL surgery. I do think the patient should discuss prehab with her orthopaedic surgeon and work with her physical therapist before surgery.
From my experience doing over 100 ACL surgeries each year, I’ve seen many patients struggle to set up physical therapy after surgery. Working with one before surgery can ensure that postoperative appointments are in place so they can start four or five days after the procedure. Plus the physical therapist can advise the patient about postoperative instructions and common mistakes other patients make.
Finally, there also seems to be proof that return to play might be faster with a prehab program. By itself, a prehab program cannot guarantee reinjury doesn’t occur or that an athlete won’t make it back to sports. But it can certainly help.
Are you an athlete who has undergone ACL surgery? Do you think that a prehab program would have helped you recover faster? If you are a physical therapist, do you have any thoughts on these programs? Share your thoughts below!
Shaarani SR, O’Hare C, Quinn A, Moyna M, Moran R, O’Byrne JM. Effect of Prehabilitation on the Outcome of Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2013;41(9):2117-2127.
Ardern CL, Webster KE, Taylor NF, Feller JA. Return to the Preinjury Level of Competitive Sport After Anterior Cruciate Ligament Reconstruction Surgery: Two-thirds of Patients Have Not Returned by 12 Months After Surgery. Am J Sports Med. 2011;39(3):538-43.