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ACL Rehab Phase 0: What To Do After An ACL Injury

Writer's picture: Aaron TurnbullAaron Turnbull

Updated: Jan 31

Rupturing your ACL can be really tough and it’s fair to feel quite helpless during the first few days. ACL injury rates continue to climb, with most athletes knowing someone who has had the surgery and gone through the 9-12 months of rehab.


After we have a confirmed diagnosis via MRI imaging, the reality is that if surgery is best option, surgery may only be scheduled until weeks later. In Australia, if you are going through the public system, there is a minimum period of at least 6 weeks (usually 3-4 months) before you will have the procedure. If you're going through the private system, the wait time is often less than a month.


But what do we do before surgery? Just sit around and wait our turn?


What we do leading up to the surgery can have a big impact on their post-surgical outcomes. Pre-operative rehabilitation, where we look to restoring as much range, strength and function of the affected knee has been shown to improve return to sport rates, reduce post-op rehab times and help prevent chronic strength deficits (2).


In this blog, I will outline important considerations throughout each step post-injury, from immediately after the injury, all the way to a potential surgical procedure.


ACL Injury: The Mechanism of Injury


Athletes can rupture their ACL doing a number of different sporting tasks like landing, pivoting, stepping, even in contact. With the ACL being the number one restraint for rotation at the knee and a secondary restraint for hyperextension, you can imagine that it can be loaded during a number of sporting manoeuvres. 85% of ACL injuries are what we call "non-contact injuries", meaning that the athlete isn't touched when they suffer the injury.


After the event has happened, athletes can present in different ways. Some are in agony and are unable to walk, whilst others may feel like they can continue (with some finishing the game) after an initial bought of intense pain. How an athlete presents in majorly contributed by what else has been damaged. Other common pathologies that co-exist with ACL injuries are meniscal tears and bony injuries.


The first step will to be to get an x-ray. Now whether you present to the emergency room or your GP, this will be the first step in ruling in/out an ACL. Now although an x-ray only shows information about bony structures (won't show a torn ACL), it is crucial to determine where there has been a leg break during the mechanism of injury. Patients that present to emergency, will often have to go to their GP to get an MRI referral as in my experience, they never provide a referral or send you to an MRI straight away at the hospital.


Now if you have been cleared of bony injury (x-ray is fine), patients should then go to an experienced physiotherapist or sports doctor, to have an assessment and to determine the likelihood of an ACL injury. Unless you meet the following CRITERIA, MRI scans are rather expensive (>$300) so it isn't best practice to rush off for one. The experienced professional will ask you further questions regarding the event and assess the integrity of the ACL, MCL, PCL, LCL, meniscus etc.


If they believe an ACL injury has potentially occurred, the next step is an MRI. This imaging technique is the gold-standard for soft-tissue imaging and shows whether the ACL is intact or not.

Here are pictures of what an intact and torn ACL looks like on MRI imaging.



ACL intact as seen on MRI

ACL injury as shown on MRI



So... what happens when an ACL injury has been confirmed? Well, there's a number of options on the management of an ACL injury, based off a number of factors:

  1. Surgery: 9-12 months rehab afterwards for a return to sport.

  2. Cross-Bracing Protocol: Braced strictly for 12 weeks following the protocol outlined here, avoiding surgery and allowing for natural healing of the ACL (still 9-12 months rehab). Ask you specialist whether you are a candidate.

  3. Conservative management: some people may be able to live their lives without an ACL. Older patients and patients that don't need to return to change of direction sports may cope without an ACL fine.


Now if you do go down the surgical pathway for an ACL injury, it's crucial you work with an experienced physiotherapist to maximise the function of your knee prior to surgery. Pre-operative rehabilitation, where we look to restoring as much range, strength and function of the affected knee has been shown to improve return to sport rates, reduce post-op rehab times and help prevent chronic strength deficits (2). I speak from experience when I say the results between those that "prehab" and those that don't, are night and day.


This is what you can expect during the pre-op phase of ACL rehab:


Aims of stage:

  • Reduce swelling and symptoms.

  • Restore >80% strength of the affected leg compared to the non-affected side (3).*

  • Restore full range at the knee.


Rehab during this stage:

  • Manual therapy from your physio to help reduce symptoms and improve range of motion at the knee.

  • Tailored home programs via our mobile app to improve knee function and strength.

  • Progression into our supervised gym-based rehab programs here at Game Time if the knee is ready for it and we have enough time prior to surgery.


*This is heavily dependant on the available pre-op rehab time. Ideally we would have 4-6 weeks.


For more information about post-op ACL rehab, injury management and pre-op ACL rehabilitation, view our ACL rehab website page or send me an email aaron@gametimeperformance.com.au




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