The truth is, every athlete is at risk to sustain an ACL tear; but no one is ever ready to endure or rehabilitate one. As rehabilitation specialists, you know just how debilitating this injury can be physically, emotionally and mentally for athletes of any level or gender. As the first line of protection after the injury is sustained, your athletes may come to you with some tough questions regarding their surgery and rehabilitation of the injury. Here’s how to prepare for three common questions you might come across:
“What’s better; a patellar or hamstring graft?”
The graft selection for ACL reconstruction is controversial and often “dealer’s choice;” whoever is performing the surgery more than likely has a certain method that they swear by and have mastered. The two most common types are hamstring tendon and patellar tendon grafts, and both are often presented with similar success rates and outcomes. However, your athlete may have done some background research and want your advice on which type of surgery to pursue. While this is not your ultimate decision, you are well within your rights to present both sides of the issue.
“Team Patellar Tendon Graft” makes a good case with solid evidence. One study concluded, “patients with hamstring tendon grafts had twice the risk of revision of revision compared with patients with patellar tendon grafts,” (Persson A et al. 2014). Another study that same year confirmed this deduction after finding an increased risk of revision with a hamstring tendon graft compared with patellar tendon grafts (Rahr-Wagner L. et al. 2014).
Worth noting, however, is that both of these studies analyzed ACL revision rates in the short-term (maximum of five years post-initial surgery). Alternatively, a 2016 study found that, at 20 years post-ACL reconstruction, “both hamstring and patellar tendon grafts continued to provide good subjective outcomes and objective stability. However, ACL reconstruction using the patellar tendon graft is associated with persisting kneeling pain and radiological osteoarthritis, compared to the hamstring tendon graft” (Pinczewski L et al. 2016).
So both have their repercussions, and both can be successful? Dr. Mike Reinold, PT, DPT, SCS, CSCS thinks so. He addressed these studies in a past article and concluded:
“When we really assess the numbers, it is clear that both graft options are great choices with low revision rates. Even though we are comparing the two, realistically the revision rates after ACL reconstruction are low for both hamstring tendon grafts and patellar tendon grafts. There are many factors that go into deciding which graft to use. “
Advise your athletes that there is no clear answer on which method is better, and to trust their physician on their treatment plan, or to seek out a second opinion. Phil Page PhD, PT, ATC, FACSM agrees. “Look for an orthopedic surgeon with years of experience with athletes. While most have their own preferences in graft choice, it ultimately depends on the patient: age, sex, sport and history all go into the equation.”
“When do you think I’ll be able to play again?”
Once again, this question is a little out of your range of certainty. Nevertheless, it may be helpful to share these statistics with your injured athlete to give them some perspective on what they need to do before they return to their sport (all data courtesy of Di Stasi, S et al. [2013]):
- Return to activity success rates range from 43% to 93%.
- The risk of a second ACL injury may range from 6% to as high as 30% and can be associated with several factors, including surgical technique, age, activity level, sex, time since surgery, and biomechanical adaptations during dynamic tasks.
- Common neuromuscular deficits might include muscle weakness, impaired dynamic joint motion, abnormal neuromuscular control.
- Post-reconstruction risk for contralateral ACL rupture may be at least twice that of graft rupture, regardless of sex, and may be indicative of residual and magnified asymmetries in neuromuscular control
- Return to higher levels of activity that require cutting, pivoting, and jumping may substantially increase the risk of a second ACL injury between 5-fold and 10-fold.
Make sure the athlete knows that, although the road to recovery will be long and tough, it is unwise to return to sport before they are 100% ready to do so. The statistics show that a lack of strength and control greatly increase the risk of re-injury; no game is worth the pain.
“How can I stop this from ever happening again?”
This question you CAN answer confidently. Identifying and treating abnormal movement patterns is absolutely crucial in both maximizing recovery and preventing a second ACL injury.
“Current evidence-based standards for postoperative rehabilitation include exercises and neuromuscular training to restore full and pain-free range of motion, maximize strength, and achieve preinjury function. Targeted rehabilitation programs are likely most effective when tailored to patient-specific neuromuscular deficits” (Di Stasi, S et al. 2013).
Dr. Trent Nessler PT, MPT, DPT has dedicated his career to researching the mechanics of ACL injury and injury prevention. If you want to learn the intricacies of assessing, rehabilitating and preventing, join him on his journey in making sports a safe place for ACL’s:
As an introduction, check out his demonstration of the improper movements that can lead to ACL injuries:
Resources;
Di Stasi, S et al. 2013. Neuromuscular Training to Target Deficits Associated With Second Anterior Cruciate Ligament Injury. J Orthop Sports Phys Ther . 2013;43(11):777–792.
Persson A et al. 2014. Increased Risk of Revision With Hamstring Tendon Grafts Compared With Patellar Tendon Grafts After Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 2014 02/01; 2017/02;42(2):285-91.
Pinczewski L et al. 2016. Radiographic Osteoarthritis, Clinical Outcomes and Re-Injury 20 Years after ACL Reconstruction: A Prospective Study Of Hamstring and Patellar Tendon Grafts. Orthopaedic Journal of Sports Medicine. 2016;4(2 Suppl).
Rahr-Wagner L et al. 2014. Comparison of Hamstring Tendon and Patellar Tendon Grafts in Anterior Cruciate Ligament Reconstruction in a Nationwide Population-Based Cohort Study. Am J Sports Med. 2014 02/01; 2017/02;42(2):278-84.
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