OSINSTITUT: What are typical challenges in therapy after cruciate ligament surgery?
Matthew Buckthorpe: There are many but of course some more important than others and some will have differing impacts on outcomes. Firstly, it’s important to consider the goals of return to sport, re-injury prevention, return to performance and long term knee health, as the four key ambitions. Some factors will impact all of these whilst others will be stronger on certain factors. For example, altered movement quality such as dynamic knee valgus will be stronger in its impact on re-injury risk than performance and RTS etc.
For me there are potential complications at different stages and it’s important to adopt a criterion based framework to ensure you are addressing the key aspects at each stage. Some issues will be impactful on early stage but should be addressed early on so they don’t cause a problem. Ultimately the late-stage goals are essential for RTS, but unless you address the earlier factors, you won’t be able to address subsequent key factors. The key initial goals and issues arising in the early stage are inability to recover joint ROM, particularly knee extensions and address pain and swelling.
Normal or optimal gait biomechanics cannot occur without appropriate joint ROM, with full knee extension an essential criterion to meet to safely progress the patient off their crutches post-ACLR. Extension loss results in abnormal joint arthrokinematics at both the tibiofemoral and PFJ, and results in abnormal articular cartilage contact pressures and quadriceps inhibition. Patients who experienced an extension deficit post-ACLR have been reported to have a five-fold higher risk of developing anterior knee pain. Other aspects of early stage are about timing and ensuring you appropriately load to minimise strength deficits, start some early gait and movement retraining and preserve fitness where possible.
Other major aspects are recovery of quadricpes strength, which is perhaps the hardest clinical aspect post ACLR. Failure to recover it will limit progress through rehab and impact ability to progress to late stage rehab and ultimately back to sport. Alongside this is general strengthening of other muscle groups and achieving sufficient strength and power in the closed chain (e.g., functional CKC strength such as squatting, jump height and rate of force development).
Movement quality restoration is a major consideration, and ACL patients typically experience movement alterations post injury and ACLR which need to be addressed. Failure to do so will increase risk of reinjury and impact performance and loading capacity.
Fitness restoration and more specifically on-field rehabilitation is a key bridge back to sport and often not completed, which impacts ability to RTS and potentially injury risk (although further research needed on injury risk). Having a OFR framework as part of the RTS continuum is essential for optimal RTS.
I group the factors across i) joint homeostasis, ii) strength, iii) movement quality, iv) fitness and sport-specific training, as well as v) psycho-social factors.
OSINSTITUT: Outcomes following injuries such as anterior cruciate ligament (ACL) rupture are unsatisfactory, with lower than optimal return to sport (RTS) rates and high re-injury risk. Why is that in your opinion?
Matthew Buckthorpe: For me this is the ability to overcome the above issues. Key factors are quad and hamstring strength deficits, altered movement quality, insufficient late-stage rehab and RTS training. Without sufficient intensity and volume of rehab, RTS will be challenging. There is a difference between RTS and return to performance (RTP) and ensuring you've restored sufficient sport-specific fitness profile important for RTP, but this to some degree will be throughout the RTS continuum (on-field rehab, return to team training, return to competitive match play and finally return to performance [Buckthorpe et al., 2018 - BJMS]).
OSINSTITUT: How do you deal with athletes who want too much too quickly, who are too impatient?
Matthew Buckthorpe: This is where criteria and education are essential. The patients need to understand the rehab journey and what factors need to be overcome and why. For example, return to running should be criteria based, in which joint ROM, pain, strength and movement quality requirements need to be achieved. Provide the patient autonomy and say you can run when you can achieve these criteria to do so. If you don't this will happen. It’s not about progressing quickly but optimally.
OSINSTITUT: How do you deal with patients who are afraid of a re-injury or who don’t „trust“ the reconstructed ACL?
Matthew Buckthorpe: For me this is where on-field rehabilitation is essential. Patients will be fearful and exposing them to progressively increasing sport-specific tasks is essential for both function. Also functional testing to identify deficits and overcome these key. Psychological cannot be separated from function and often fear is due to defictis such as quads strength, movement issues, lack of sport-specific training. Help them feel ready by being able to 'eventually' when they've achieve the criteria to perform sport-specific movement on the pitch and simulate the demands of the sport. Nothing helps feel ready for doing sport than doing the sport (in a controlled environment in the first instance).
OSINSTITUT: Do you have any suggestions on literature for our readers concerning ACLR therapy?
Matthew Buckthorpe: I'd in a biased way I'll promote my clinical commentaries and review papers, which I believe are some of the best resources available. I wrote these specifically to support clinicians with evidence translated in practice in a workable framework. These are:
- Buckthorpe M, Gokeler A, Herrington L, et al. Optimising the Early-Stage Rehabilitation Process Post-ACL Reconstruction. Sports Med. 2023 Oct 3. doi: 10.1007/s40279-023-01934-w. Epub ahead of print. PMID: 37787846.
- Buckthorpe M, Della Villa F. Recommendations for plyometric training after ACL reconstruction - a clinical commentary. Int J Sports Phys Ther. 2021 Jun 1;16(3):879-895.
- Buckthorpe M. Recommendations for movement re-training after ACL reconstruction. Sports Med. 2021;51(8):1601-1618.
- Buckthorpe M, Danelon F, La Rosa G, et al. Recommendations for hamstring function recovery after ACL reconstruction. Sports Med. 2021;51(4):607-624.
- Buckthorpe M, Tamisari A, Della Villa F. A ten task-based progression in rehabilitation after ACL reconstruction: from post-surgery to return to play - a clinical commentary. Int J Sports Phys Ther. 2020;15(4):611-623.
- Della Villa F, Buckthorpe M, Grassi A, et al. Systematic video analysis of ACL injuries in professional male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 consecutive cases. Br J Sports Med. 2020;54:1423-1432.
- Buckthorpe M, Della Villa F. Optimising the 'mid-stage' training and testing process after ACL reconstruction. Sports Med. 2020;50:657-678.
- Buckthorpe M, Pirotti E, Villa FD. Benefits and use of aquatic therapy during rehabilitation after ACL reconstruction -a clinical commentary. Int J Sports Phys Ther. 2019 Dec;14(6):978-993.
- Buckthorpe M, Stride M, Villa FD. Assessing and treating gluteus maximus weakness - a clinical commentary. Int J Sports Phys Ther. 2019 Jul;14(4):655-669.
- Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field rehabilitation part 1: 4 pillars of high-quality on-field rehabilitation are restoring movement quality, physical conditioning, restoring sport-specific skills, and progressively developing chronic training load. J Orthop Sports Physical Ther. 2019;49:565-569.
- Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field rehabilitation – Part 2 A 5-stage programme for the soccer player: linear movements, multidirectional movements, soccer-specific skills, soccer-specific movements, and modified practice. J Orthop Sports Physical Ther. 2019;49:570-575.
- Buckthorpe M. Optimising the late-stage rehabilitation and return-to-sport training and testing process after ACL reconstruction. Sports Med. 2019;49:1043-1058.
- Buckthorpe M, La Rosa G, Villa FD. Restoring knee extensor strength after anterior cruciate ligament reconstruction: a clinical commentary. Int J Sports Phys Ther. 2019 Feb;14(1):159-172.
