Returning to Sport following ACLr: Bridging the Gap between Physio and S&C

Injury to the anterior cruciate ligament (ACL) is one of the most severe injuries an athlete can sustain, and returning to sport (RTS) post ACL reconstruction (ACLr) surgery is a complex process, requiring an athlete to overcome significant physical, physiological and psychological barriers (1, 2). The RTS process requires a multidisciplinary team to restore knee function and to protect against re-injury (Figure 1), which vary in size, composition and expertise, depending upon the context and resources available (3).

Figure 1.

The 'Multidisciplinary Team'.

Note. (3)

Whilst orthopaedics and physiotherapy play a central role during early stages of rehabilitation (immediately post-injury, pre-operative and immediately post-surgery), it is the role of the strength and conditioning (S&C) practitioner to assist in adequately preparing the athlete to return to a sport specific envelope of function during mid-later stages of rehabilitation (from ~8-12 weeks onwards).

This multidisciplinary team approach is commonplace in the private sector or within professional teams or organisations, however, in the public sector, it is not as common. Often athletes in the public sector are referred to physiotherapy post-surgery, then, are often discharged after ‘completing’ physiotherapy at ~12 weeks post-surgery (with obvious residual gate abnormalities, neuromuscular impairment and significant interlimb strength and muscle mass asymmetries etc.), without completing (or even beginning), any structured or formal S&C training. Unfortunately, this is something I have witnessed on numerous occasions, and this system leaves athletes with lifelong aberrant movement patterns, underprepared to RTS, and exposed to future re-injury.

The ‘Gap’ – Why we are getting underprepared athletes returning to sport:

This gap between physiotherapy and S&C has many interpretations, such as outlining the literal gap in expertise (as per the respective scope of practice for each discipline), or a more metaphorical, contextual gap as the one highlighted in this article. For our purposes, the ‘gap’ is based on my own experiences, and refers to the space between where physiotherapists typically reach the end of their scope of practice and reduce contact time with an athlete (after restoring a return of ‘baseline’ function, i.e., reduced pain, limited to no swelling, acceptable range/s of motion, return to normal activities of daily living etc.), and where the transition to an S&C practitioner (in an integrated/multidisciplinary team model) would typically exist. I believe this gap is created by a multitude of factors, namely, a lack of understanding for what S&C is within the public sector (what S&C coaches can and can’t do), the financial burden associated with injury (self-financing training is expensive), an urgency to return to sport as soon as possible, and a lack of awareness on the athlete’s behalf for how significant an ACL injury is (the residual neuromuscular impairments and the implications on future health and lower-limb function).

And it is within this gap that the opportunity for athletes to be allowed to return to sport too soon is afforded, as there is no practitioner actively guiding the rehabilitation process during this stage (physiotherapy has ended, and no formal S&C training is undertaken), and the athlete therefore becomes responsible for coordinating the transition from injury to performance themselves.

Challenging the role of S&C in the rehabilitation space:

Traditionally speaking, physiotherapists are seen as the primary practitioners during injury rehabilitation, and S&C professionals are often viewed as being responsible for enhancing performance related qualities in ‘healthy’ or non-injured athletes. And whilst this is not necessarily incorrect, I believe this bookmarking of roles has led to a misunderstanding as to what S&C practitioners are capable of in the rehabilitation space, and how much overlap exists between the disciplines, if the time and resources are afforded. While it is not within the scope of an S&C coach to clinically diagnose injuries or treat pain, there are commonalities within skillsets that qualified and competent S&C practitioners share with physiotherapists, such as prescribing exercise to restore function and improve movement literacy, and a deep understanding of human anatomy. Additionally, S&C coaches are highly skilled and knowledgeable in areas crucial within rehabilitation (and within areas in which physiotherapists are not extensively trained), such as sports science testing and evaluation, principles of training such as progressive overload, programme design, biomechanics and skill acquisition, exercise physiology and movement screening and injury risk profiling.

Bridging the gap - The multidisciplinary team approach:

There is no question that the best rehabilitation outcomes for athletes occur when physiotherapy and S&C are combined to offer an integrated approach. This approach best utilises the skillsets of each discipline, whilst creating an environment for open communication that encourages collaboration and knowledge sharing. Above all, the fluid transition between disciplines can serve towards retaining athlete engagement, which can promote more successful rehabilitation outcomes by increasing attendance and adherence to a structured plan (something that is lost in the ‘gap’ if not delivered within an integrated approach).

Summary - S&C practitioners can do more:

Rehabilitation post ACLr requires an extensive, multidisciplinary approach, and traditional models of rehabilitation (i.e., physiotherapy in isolation) do not adequately prepare athletes for the rigours of competitive sport. S&C professionals can do far more than just help non-injured athletes get stronger and faster and should be considered an integral part of the rehabilitation process, with critical knowledge and expertise pertaining to late-stage rehabilitation management and RTS training prescription. S&C training should therefore be viewed as a need to have, not a nice to have, and where possible, practitioners and/or facilities working with recreational athletes within the public sector should aim to create opportunities where physiotherapists and S&C coaches can work in unison, offering a singular rehabilitation service designed to provide a well-rounded RTS programme, leveraging the skillsets of both disciplines to ensure each rehabbing athlete receives the comprehensive care they need.

 

References:

1.        Jordan, M., & Bishop, C. (2023). Testing Limb Symmetry and Asymmetry after ACL Injury: Four Considerations to Increase its Utility. Strength & Conditioning Journal. 46(4), 406-414. DOI: 10.1519/SSC.0000000000000821

2.     Buckthorpe, M. (2019). Optimising the Late-Stage Rehabilitation and Return-to-Sport Training and Testing Process After ACL Reconstruction. Sports Medicine, 49(7), 1043–1058. https://doi.org/10.1007/s40279-019-01102-z

3.     King, E. (2023). Rehabilitation after ACL reconstruction; the Aspetar way. Aspetar Sports Medicine Journal. 23(29), 284-290.