Knee Reconstruction Recovery and Training

author : AMSSM

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In order to set yourself up for the best chance for a safe return to triathlon you should adhere to all your surgeon and physical therapist’s recommendations. Direct your energy into each rehab goal.

Member Question

So after tempting fate for a few years, I finally managed to injure my knee playing basketball. Long story short, I have a dislocated knee, ruptured ACL, cartilage and torn medial ligament. All this was done playing social basketball whilst getting ready for Cairns IM. Needless to say, Cairns IM 2014 is off the radar. 

I had the conventional hamstring graft reconstruction recently. All went well and now I am in the early recovery mode with plenty of ice and elevation etc. 

My wife and surgeon think I'm crazy to be even thinking I can do Noosa Tri in November 2014. I think I can and I have it as my recovery goal. 

Can I go back to training?  Should I be concerned about anything or any long term issues?

Answer from Anna Monroe, MD FACEM
Member AMSSM 

I am sorry to hear about your injury, and I know you must feel quite frustrated. I admire your determination to return to sport, and a recent review article actually did find that setting and keeping goals can improve rehabilitation after an ACL injury. However I would encourage you to work very closely with your surgeon and physical therapist to determine appropriate goals. Let me share some general guidelines about ACL rehabilitation that I hope you will find helpful. Keep in mind that there are no universal rules for and many individual factors surrounding the timing of an individual’s return to sport.

It sounds as if you are currently in the early postoperative phase of rehabilitation which usually lasts 4-6 weeks. To advance your rehabilitation past this point you need to accomplish the following goals: be able to walk without crutches and with a normal gait, be able to fully extend and flex the knee, and have very little or no joint swelling. Since it sounds as if you may have also injured your meniscal cartilage and medial collateral ligament (MCL) it is important to adhere to any bracing recommendations and restrictions on full range of motion that your surgeon has given you since you might need to go a little more slowly than someone without an associated cartilage injury. Some exercises you might perform under the supervision of a physical therapist include pedaling a stationary bike, working on kneecap motion, doing straight leg raises or other quadriceps strengthening movements, working on balance, and starting to work on strength and flexibility of your legs in general.

Over the next several months you will continue to advance your exercises with goals of restoring your full strength and returning to the normal biomechanics that will set the stage for eventual competition in triathlon. In addition to continuing to focus on normal quadriceps strength, you will likely include exercises for the back, hips, and abdominal musculature. Sometime during this phase returning to a slow running program may begin. One guideline for starting a running program suggests that you need to have quadriceps strength of at least 70-75%, have full and painless motion of the knee, and be able to walk with a normal and quick gait for at least 15 minutes. Running should progress slowly by no more than 10-15% per week and should stop if pain or joint irritation develops.

Finally if things go well you can think about resuming an intense training program and returning to racing. Again when this happens really depends on the type of graft you have and its position, how well your knee has healed, any associated knee injuries you sustained, and the specific demands of the sport. Since knee osteoarthritis is a risk following an ACL injury especially when combined with injury to the meniscus, you may want to lengthen your rehabilitation time especially in the setting of cartilage injury.

One piece of good news is that some evidence suggests that more people return to running and biking after an ACL reconstruction than sports like soccer and football. However according to the advice of many experts, rapid return in the time frame of 3-6 months may not be a great idea because your body and the graft have not had enough time to fully heal. An example from soccer is that it took high level players in the Union of European Football Associations (UEFA) 7 months to go back to any training, 10 months to go back to a normal training schedule, and one year to return to competition.

Training in the final months of ACL rehabilitation can include sprinting and plyometric exercises if your quadriceps strength is at least 85% and your knee is otherwise doing well. You will likely want to continue to focus on your rehabilitation exercises and increase your back, hip, and abdominal strength. Paying attention to core strength may help prevent an ACL injury in your other knee or a rupture of your graft. Your surgeon’s expertise can help guide you towards a safe resumption of activity.

In summary your goals and motivation could likely really help you during this journey of ACL rehabilitation. However in order to set yourself up for the best chance for a safe return to triathlon you should adhere to all your surgeon and physical therapist’s recommendations. Direct your energy into each rehab goal, and celebrate those victories as you achieve each step. Consider whether there are also some personal goals unrelated to triathlon participation that can inspire you during this time. Good luck in your rehabilitation!

Anna Monroe, MD FACEM, CAQ Primary Care Sports Medicine

References:

1. Rehabilitation and return to play after anatomic anterior cruciate ligament reconstruction.Yabroudi MA, Irrgang JJ. Clin Sports Med. 2013 Jan;32(1):165-75. doi: 10.1016/j.csm.2012.08.016. Epub 2012 Oct 13. Review.
    
2. Psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review. te Wierike SC, van der Sluis A, van den Akker-Scheek I, Elferink-Gemser MT, Visscher C. Scand J Med Sci Sports. 2013 Oct;23(5):527-40. doi: 10.1111/sms.12010. Epub 2012 Nov 4. Review.
    
3. Eight clinical conundrums relating to anterior cruciate ligament (ACL) injury in sport: recent evidence and a personal reflection. Renström PA. Br J Sports Med. 2013 Apr;47(6):367-72. doi: 10.1136/bjsports-2012-091623. Epub 2012 Aug 31. Review.
    
4. Sport-specific outcomes after anterior cruciate ligament reconstruction. Warner SJ, Smith MV, Wright RW, Matava MJ, Brophy RH. Arthroscopy. 2011 Aug;27(8):1129-34. doi: 10.1016/j.arthro.2011.02.022. Epub 2011 Jun 12. Review

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date: July 24, 2014