posts FROM PROFESSIONALS - july 3, 2018

Kevin Cheng    is a registered physiotherapist at CBI Health Group. He holds a Master's degree in Physical Therapy from Queen's University, and a Bachelor of Science - Kinesiology degree from the University of Waterloo. Throughout his career, he has worked at various settings in the GTA, and has helped many patients in making optimal recovery from an ACL injury.

Kevin Cheng is a registered physiotherapist at CBI Health Group. He holds a Master's degree in Physical Therapy from Queen's University, and a Bachelor of Science - Kinesiology degree from the University of Waterloo. Throughout his career, he has worked at various settings in the GTA, and has helped many patients in making optimal recovery from an ACL injury.

the importance of rehabilitation in ACL recovery


So the athlete has recently sustained an ACL injury. What can the athlete do?

Knee injuries can be debilitating but the symptoms can be managed and optimal recovery can be achieved. It is completely normal for the athlete to feel disappointed about the injury. But if the athlete’s knee injury is taken care of optimally, the symptoms, debilitation, and disappointment can be reduced. The sooner the athlete can get back into the activities the athlete loves to do, the better the athlete will feel. With proper rehabilitation the athlete can return to components of their activity sooner, through gradual return to play/activity. Gradually introducing components of their activity/sport can improve rehabilitation adherence, decrease boredom, and increase likelihood of recovery. 

There are many steps the athlete can do to ensure the athlete achieves optimal recovery from a knee injury. The first step is important. Do not just push through injury. With any physical activity, whether it be sports, dance, or martial arts, immediately after injury the athlete needs to stop the aggravating activity. The more time the athlete invests in taking care of the injury now, the better outcomes the athlete will have later on and the less time the athlete spends injured. 

Next go see a rehabilitation professional such as a Physiotherapist. A Physiotherapist can give the athlete strategies to manage the symptoms and impairment of the injury.  A Physiotherapist often can diagnose the severity and type of knee injury before obtaining medical imaging (X-ray, ultrasound imaging, MRI) and the athlete can start rehabilitation right away. For knee sprains/tears, it is often unwise to wait for medical imaging before seeking a physiotherapy assessment because the athlete is potentially delaying recovery. The physiotherapist can implement various modalities such as soft tissue mobilizations, electrotherapy, cold/hot therapy to help decrease pain during the time it takes the injury to heal naturally. 

Most importantly, the physiotherapist can prescribe the athlete exercises to begin right away to maintain range of motion, strength, and function. The more the athlete maintains range of motion, strength, and function the less debilitating the injury will be and the better the athlete’s mental state will be after an ACL injury. Once functional ability to run and pivot is returned, gradual return to play can commence.  



What if the athlete needs surgery?

Whether recommendation for surgery is indicated for a knee injury has many considerations that we will elaborate on in another article, but for the purpose of this article we will briefly touch on it. Non-surgical management of isolated ACL tears are likely to be successful for patients:

+ With partial tears and no instability problems
+ With complete tears and no instability issues during low-pivoting-demand sports, and who are willing to give up high-pivoting-demand sports
+ Who do light manual work without pivoting or live sedentary lifestyles
+ Whose growth plates are still open (children) 

Surgery may also be warranted for combination injuries to the meniscus and full tear of the ACL.             

Often, patients who have knee injury diagnoses that are indicated for surgery may likely benefit from a first-line strategy of physiotherapy. Physiotherapy exercises may even improve post-surgical outcomes such as decreased post-surgical weakness, since patients who do exercises pre-operatively start post-operative rehabilitation at a higher level of knee strength.

The physiotherapist will educate the athlete for recommendation of surgery after the initial assessment or after a first-line treatment program of physiotherapy. If surgery is considered, the Physiotherapist can recommend the athlete to obtain a referral for an orthopedic surgeon consultation. During this time, the athlete can continue their home exercise program to maintain range of motion, strength, and function. 



What if physiotherapy exercises are boring, and the athlete wants to return to their sport soon?

Even as a Physiotherapist, I agree home exercise programs can be boring. But, firstly it is important to remember the goals of return to sport and that every time the athlete does exercises to the parameters set by the physiotherapist this helps the athlete achieve their goals.

The biggest idea I want to emphasize in this article is that rehabilitation of the injury doesn’t mean the athlete cannot perform their sport in any way. There will be aspects of the sport that the athlete cannot perform yet such as cutting, lateral running, and twisting. But the athlete can definitely isolate the sport into components that the athlete can do. For example, once an injured basketball player has a pain-free quarter squat, the basketball player can begin working on stationary dribbling drills and free-throws. A physiotherapist can progressively introduce components of return to sport as the athlete improves so that the athlete does not “get rusty”. This will help decrease boredom. Often, isolating components of the athlete’s sport will improve the overall game of the athlete. The athlete can work on components that the athlete never had a chance to work on before. For example, the “Shaquille O’Neal” basketball players can improve their free-throws while recovering from an ACL injury. 



After the physical barriers, such as range of motion, strength, and function have been taken care of, there are times where the barriers are no longer physical. After a long period of rehabilitation and being away from competitive sport, a full return to sport can feel jarring. It is possible that athletes can become mentally paralyzed from the fear of re-injury and having to go through the rehabilitation process again. There may also be social barriers. Sport and physical activity is often social, after being away from a social setting, the return may be difficult, especially to a less familiar team if changes have been made. Also, there may be cases where the body is ready but mentally, the athlete just does not feel ready. These are some cases where a physiotherapist can refer to other experts who focus on mental health such as a Psychologist, Psychotherapist, Psychiatrist, or Occupational Therapist. These mental health professionals may be able to use mental techniques, teach coping strategies, or plan gradual exposure for the athlete. It is important for athletes to seek rehabilitation professionals so they can take the lead in the gradual return to activity and if needed other experts can be referred to. 


To summarize, after sustaining a knee injury, stop the aggravating activity immediately, see a rehabilitation professional as soon as possible such as a physiotherapist, follow your therapist’s recommendations and exercise program to maintain or improve function, surgery may or may not be recommended during the physiotherapy program, eventually a progressive return to sport is implemented, and if necessary, referral to mental health professionals. It is okay to be disappointed after an injury, and as long as the athlete takes the necessary steps in their rehabilitation, there will be higher chances of optimal recovery and a successful return to sport. This will reduce the time away from the activity that the athlete loves to do and maintain a positive mood.