Rehabilitation after ACL Repair
Rehabilitation after ACL Repair in children and adults is similar but there are also some differences. We use the Tanner scoring system to guide both our management and our rehabilitation.
In terms of rehabilitation, we differentiate between Tanner 1 and 2 - the very young ones, generally speaking less than 13 in boys and less than 12 in girls - and Tanner 3 and 4 which include adolescents up to skeletal maturity.
The more skeletally mature group
The 3s and 4s we treat like adults, depending on how mentally mature they are. In these young people and in adults we allow a full range of motion and full weight bearing from day 1. I don't encourage the patients to walk around too much on the repaired knees - it's just a matter of getting the range of motion going for the first two weeks, and getting the quads firing with the physiotherapist. Then we progress into an extended ACL rehab programme which sees many of them back to full sport at 12 weeks, including contact sport by 4 months.
This rehabilitation approach is very unique to repair. If we had replaced the ACL tissue via a standard reconstruction they would not have been allowed to do twisting and turning sports for at least 9-12 months. So for all athletes, repair is obviously a no-brainer if you want to get back to activity sooner than 9 to 12 months.
There has been some very good work done by Rob Janssen (who is past president of the Dutch arthroscopy society). He recently had his PhD thesis accepted, which was based around looking at grafts and how well they have incorporated following ACL surgery. The interesting thing is that we as ligament surgeons assume at 12 months that patients are good to go and return to sport, but he found in fact a significant number of ACL reconstructed grafts are not incorporated by this stage, and it may be even 2 or 3 years before they are fully incorporated. Sadly, when we allow patients to go back to sport at 9-12 months we see early failure in a significant proportion and this is primarily due to the fact that the grafts haven't healed.
But when it comes to a repair, the healing response, if it is going to work, works within 12 - 16 weeks, so that patients can get back to full activity at this early stage. Gordon MacKay, Glasgow surgeon and my good friend, looked after a Scottish bobsleigh olympic athlete who tore his Achilles tendon and he often shows the videos of him rehabbing, which just don't look real in terms of how quickly he was able to rehab from a repair of his Achilles tendon using an internal brace technique. Obviously an Achilles tendon is not the knee, but the principle of repair and internal bracing is similar. This patient was able to re-join the Scottish team at three months having had that major intervention of a repair and internal brace.
So rehab is much quicker and patients can begin running at 9-12 weeks, perhaps even sooner. I have a soldier patient who actually told me he was playing football at 6 weeks. This is not something I encourage but I am sure that in certain cases the ACL repairs do heal earlier enough for patients to return to a high level of activity at such an early stage. I think we need to move with caution and work out the process more scientifically or have a system in place such that we can work out when a patient is fit to return to sport, but universally it it 12-16 weeks to full contact.
The younger patient
In the young child, it can be quite frightening having an operation and waking up in pain and discomfort, so to minimise that I splint the knee in plaster. I particularly do this for the little ones - the 5 or 6 years olds or so - all go into plaster.
After 10 days the plaster is removed and the patients begin to mobilise with crutches. For the very little ones their parents push them around in a wheelchair or carry them and they just manage more slowly and also more carefully because of the concern around compliance.
Then they go into a customised brace to allow range of motion but give them some protection.
I also keep them off sport for 4 months before I allow them to return. One of my cases - a six year old - his mother and I decided because he is such an active little chap to keep him off contact sport for 12 months but when he did return I was pleased to hear that he had won sports day for his year - he is a very sporty chap and has been one of the triumphs of this series in terms of how he has done. I also have an 18 year old girl who was able to start training with the adult England lacrosse team at a very early stage.
The jury is still out when it comes to being sure that a patient is safe to engage in full sporting activities after both reconstruction and repair. But what we do know is that repair patients get safely back to sport a lot earlier than those with reconstructions.
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