ACL Injuries and Where We Are Going Wrong

by Jun 12, 2019

From a patient who has suffered two ACL reconstruction’s consecutively over a 2-year period, I understand how traumatic they truly can be.

In Sydney we have one of the highest re-injury rates of ACL reconstructions. Up to 40% of patients have been reported to suffer a subsequent tear in the United States (Webster & Feller, 2016). But unfortunately, due to the complex nature of this injury there are many factors involved in the re-injury.  It’s only now we are paying much closer attention into how this injury should be rehabilitated.

What have we learnt over the past 5 years:


  • A simple 5-week pre-operative rehabilitation program called the NAR programme had a higher score in the KOOS subscale (knee osteoarthritis outcome score).
  • 72% of ACL reconstruction patients returned to pre-injuy level at 2yrs follow up with 10 physiotherapy sessions of neuromuscular training vs 63% whose pre-op physio did not (Failla et al, 2016).
  • 5 weeks intensive pre-op physio that achieved 90% limb symmetry in quads & hamstring strength and single leg hop distance prior to ACL reconstruction resulted in superior knee function outcomes at 2 years post-op (Grindem et al, 2015).

Graft Choice:

To date there is no graft that appears to be more superior than others. Historically in Australia, the hamstring and patella tendon’s are commonly used.

When can I return to sport?

Previously it was thought that waiting approximately 12 months to return to sport was enough time for the graft to heal. More recently both physiotherapists and Orthopaedic Surgeons have moved to a criteria-based assessment for return to sport. This test is a combination of strength measures, hop tests, patient reported symptoms, and psychological readiness.

  • Inadequate quadriceps symmetry with >10% difference to the non-operative leg is much less likely to have a successful return to sport.
  • For every 1% difference in quad strength the risk of re-injury increased by 3%.
  • Patients who passed the ‘return to sports criteria’ there’s a 84% lower knee re-injury rate.
  • In a study by Grindem et al, (2016), 1 of 19 patients who passed the “return to sports criteria’ suffered re-injury. Additionally it was found that re-injury occurred between the 3rd and 22nd post-operative month. This suggests that even after clearance at the 1 year mark, patients are at a high risk of re-injury.

Reece Jones
Principal Physiotherapist
Set In Motion Physiotherapy


Failla, M., Logerstedt, D., Grindem, H., Axe, M., Risberg, M., Engebretsten, L., Huston, L., Spindler, K., & Mackler, L. 2016. Does Extended Preoperative Rehabilitation Influence Outcomes 2 Years After ACL Reconstruction?: A Comparative Effectiveness Study Between the MOON and Delaware-Oslo ACL Cohorts. The American Journal of Sports Medicine, 44(10).

Grindem, H., Granan, L., Risberg, M., Engerbretsten, L., Snyder-Mackler, L., & Eitzen, I.2016. How does a combined pre-operative and post-operative rehabilitation program influence the outcome of ACL reconstruction 2 years after surgery? A comparison between patients in the Delaware-Oslo ACL Cohort and the Norwegian Knee Ligament Registry. British Journal of Sports Medicine, 49(6).

Grindem, H., Snyder-Mackler, L., Moksnes, H., Engebretsen, L., Risberg, M. (2016). Simple decision rules can reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine, 50(13), 804-808.

Webster K, & Feller J. 2016. Exploring the High Reinjury Rate in Younger Patients Undergoing Anterior Cruciate Ligament Reconstruction. The American journal of sports medicine. 44(11):2827-32.

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