ACL Injury Prevention Guidelines for Athletes

ACL Prevention and Rehabilitation

• Primary prevention for ACL injury can reduce injury rates by 52-88% (literature reviews suggest).
• Prevention programs seem to work better for males than females, but are still effective for both.
• ACL injury severity may also be reduced with these programs.
• Prevention programs should start in the off-season and progress into the regular season, with a warm-up before practice and games.

ACL Rehabilitation

• Patient education should temper patient expectations, set thresholds for a successful recovery, and teach the patient about activity modulation, weight-bearing status, RoM precautions, crutch use, icing, and brace use.
• Manual therapy can increase mobility of the patella and address myofascial dysfunction after surgery.
• Clinical practice guidelines suggest advocating for prehabilitation, encouraging early mobility, weight-bearing, ice, and bracing, and promoting strength and motor control.
• Guidelines argue against rehab lasting longer than 16 weeks.

Protocols for ACL Rehabilitation

• Protocols usually fall into four categories: accelerated, regular, hamstring graft, and concomitant surgery for comorbid pathologies.
• Differences between protocols involve specific precautions, like not challenging the hamstrings after a hamstring graft, and progression through stages.
• Most rehab protocols flow through six stages, from preoperative visits to return to activity.

Importance of ACL Prevention and Rehabilitation

• All 12-25 year old athletes in ACL-risky sports should undertake ACL prevention protocols, regardless of gender or dynamic valgus and weakness.
• Up to 30% of patients have a second ACL rupture within a few years, and 50% go on to have meniscus surgery within 5 years.
• OA rates climb close to 50% for those with a comorbid condition.

Secondary Prevention and Return to Sport

• Patients who have already experienced ACL tears should participate in daily activity and maintain a healthy BMI to reduce the risk of re-tear.
• Patient education should include information on re-tear rates, especially for athletes returning to pivot sports.
• The re-tear rate drops for every month you wait to return to sport, up to 9 months.

Effective ACL Prevention Programs

• Effective programs work on core, hip, and knee control, and include strength and plyometric training.
• Knee-only programs don't work, and programs that focus on balance have been shown to increase injury risk.
• The longer the exercise session, the higher the frequency, and the more compliant the athlete, the better the injury prevention.

Pre-Surgical Rehabilitation (Prehabilitation)

• Prehabilitation has mixed but positive evidence, with increases in quad strength, single-leg hop testing, return to sport ability, and self-reported measure scores at 3-months and 2 years.
• Patient education should include discussing expectations, return to sport, and functional events.
• Informing patients about return to function thresholds increases compliance, and those who pass return to sport batteries have a 32% lower re-tear rate.

Patient Characteristics and Risk Factors

• ACL tears typically present with deep, diffuse pain surrounding the knee.
• Patients are typically athletes between 15-40 who participate in a pivot sport, and are 2-8 times more likely to be female than male.
• Risk factors for ACL tears include fatigue, generalized laxity, decreased ACL size, hormonally influenced changes in laxity and motor control, and lower peak force production.