Welcome to the PT Rebels Podcast.

This is the place to learn how you can become a PT rebel and take charge of your own health and wellness. We will help you find answers to your questions about pain, injury, and the path towards healing in the most efficient and effective way possible.

I’m your host, Dr. Gina Fick.

On today’s episode, we are going to review updates in regards to ACL rehab guidelines and return to sport progression. Recently in the clinic, we’ve observed patients who are being released for return to sport, really either too early or when they’re not prepared for return to sport based on strength. Um, muscle asymmetries. I feel like a lot of these athletes aren’t being appropriately tested and guided throughout the rehab process, and they come to us 6, 8, 10 months after ACL reconstruction with 40, 50, 60% strength, asymmetry, side to side. They are not psychologically ready to return to sport. They’re physician or physical therapist may have tested them, may not have tested them, and just said, Hey, you know, it’s. It’s been six months, you can start doing some soccer specific activities again. Or, Hey, it’s been nine months and we think you’re good. Just wear this brace and you can start playing. And the patients come to us from other healthcare providers or other situations where they really feel inadequately prepared for return to sport. And I just wanted to talk about today some of the ways in which we test athletes and we prepare athletes and some of the current guidelines. For return to sport and for ACL, uh, rehabil rehabilitation guidelines so that we can adequately treat these athletes and prepare them well for return to sport and help reduce their risk of future injury. So some commonly held beliefs regarding ACL injury really need to be challenged by the latest research to help improve patient outcomes and to decrease the risk of re-injury. And these key updates are based on the article by Brinley Etal in 2022. That article discusses incorporating the latest research combined with clinical data in order to provide a current, realistic and clinically benchmark strategy for ACL rehabilitation. Oftentimes what we see in the clinic is that patients are treated initially for two or three times a week for six to eight weeks. That their insurance pays for that, that it’s guided by their physi physician protocol and the prescription. And after that, sometimes the, the patients really fall off because either their insurance stops paying or they have a clinician who isn’t as experienced and functional progression after that more acute phase of rehabilitation. And so. The ball’s getting dropped and something’s happening, um, that we’re continuing to see in our clinic or patients just really aren’t adequately prepared for return to functional activity and return to sport. So there’s some key updates in the practice guidelines by B Brinley Atal in 2022 that include the frequent and accurate use of strength testing for quadriceps. And it also includes delayed return to sport timeline. So what used to be a full return to sport at six months. It’s now being recommended that athletes don’t return to sport at least nine, but more likely 12 months after, uh, ACL reconstruction. In terms of updates for the ACL rehabilitation guidelines, there’s also recommendation that we immediately use open chain kinetic exercise. One of the things that. We were taught years and years ago, was that you didn’t do open chain. Seated knee extension or open chain knee exercises because that would place undue stress on the ACL due to shear forces. And that is just an old strategy and it’s something that, um, has really been detrimental to, um, in terms of increasing quad strength and increasing functional progression. So we’ll talk about a little bit about that more later. Um, in terms of some other updates, we also have criterion based progressions for running, sprinting, plyometrics, agility, cutting and pivoting, and return to competition. So today what I’d really like to hone in on is how. Can our patients and how can we as physical therapy providers advance the physical therapy and ACL rehab guidelines for our patients so that they are not 6, 8, 10, or 12 months down the road was significant asymmetries and functional limitations. One of the things that’s really perplexing is the persistent reluctance or resistance to include lower extremity open chain. Exercises, and again, what those are, for those of you who might not know, it may be like a seated knee extension on the end of a table or a seated seated knee extension, a piece of equipment or other types of exercises where the foot is not planted on the ground. So. Some physical therapists still have a reluctance to prescribe those open chain exercises, which is really hard to understand at this point, given the evidence of relatively low strain on the ACL during the open chain knee extension. And the poor quadricep strength outcomes after ACL reconstruction. Like I said, we’re seeing a huge number of patients coming out of these rehabilitation programs who have significant quadriceps asymmetries, and that’s really concerning for us. Such these beliefs are really prevalent among clinicians who maybe haven’t kept up with the research or don’t have a good understanding of these peak ACL strain values. Between open chain and closed knee exercises. In light of the low strain measures observed with these isolated open chain knee extension exercises, the University of Delaware ACL reconstruction guidelines have adapted to include open chain knee extension through full range of motion immediately after surgery. And why this is important is because we are seeing a decreased rate of ACL asymmetries. When these open chain knee extension exercises are started immediately versus just delayed 2, 3, 4 months down the road, so when patients come into the clinic after ACL reconstruction, we are going to immediately start these open chain knee extension exercises in addition to other modalities such as blood flow restriction training, we’re going to. Consistently, consistently and frequently measure quadricep strength. We do that not just by doing a manual muscle test, but we use a handheld isometric dynamometer. Called a vault dynamo that gives digital force output readings during a seated knee extension per se, and that helps us understand exactly where they’re at in terms of their force production from that muscle compared to the non-surgical side. And we are going to measure that quite frequently. We also use vault force decks, force plates, so that we can measure force production and force absorption capabilities down the road when we’re doing more functional testing. And advising for return to sport guidelines. Another additional consideration that’s extremely important to look at and that the evidence has shown us is essential, is to look at the athlete’s psychological readiness for return to play. It’s obvious. That it’s essential to look at their sport specific physical preparedness, but we can’t lose sight of their psychological readiness for return to that sport. Are they in their head, mentally ready to return to that sport? Do they feel confident? Do they have a lot of fears? Do they have fears? Returning to the basketball court and cutting and landing and boxing out and going up for rebound, do they have fears going back to the soccer field and cutting it at full speed? So they need to be psychologically ready. And evidence shows that if they’re not, their risk of ACL injury actually increases. The minimum return to sport criteria include at least nine months post-operation rehabilitation. A greater than 90% quad strength symmetry greater than 90%. On all hop testing and greater than 90% on the knee outcome survey activities of daily living and the greater than 80% on ACL return after injury scale. So the return to competitions to be stepwise, ensuring that the athlete has achieved. Pre-injury conditioning levels and that they can perform a maintenance and secondary prevention program at least two times a week prior to being released for return to sport. A physician or PT cannot just release these athletes in the office and expect them to return to play without placing them at a significant risk for re-injury, especially in light of the fact that they may have significant asymmetries that have not been tested or discovered through proper testing. Such as with the force plates or through handheld dynamometer testing in addition to the sports specific return to sports scales that we use. So if you are an athlete and you are working with a provider who does not do these things or, or do not have the capabilities, we highly, highly, highly recommend that you talk to your physician or you come talk to us about how we can help you be able to. Have a better idea if you are ready to return to sport by doing specific testing measures that look at how well you are able to jump and land and absorb those forces, as well as produce forces, right? Leg versus left leg, and how the, uh, any fatigue effects that you may have during that testing. So that. You feel fully confident to return to play, whether that be on the basketball court, on the soccer field, on the tennis court, whatever it may be, that you feel completely psychologically and physically ready for the demands of your sport and so that you don’t have an increased risk of ACL re-injury.