Part 3: Successful outcomes following ACL reconstruction

Physical + Mental = rehabilitating the entire athlete

So, in blog 1 we noted that although cleared for Return to Sport by their surgeon, and having passed certain physical measures, almost 1/5 of individuals following ACLR aren’t returning to any sport, and over 1/3 of individuals aren’t returning to their pre-injury level of sport, despite RTS being a commonly cited reason for undergoing ACLR in the first place.

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Why might this be?

-       Lack of confidence: The main reason (28% of respondents) for not returning to play at 1-7years post-op was not trusting the knee.

-       Deciding not to risk re-injury and the consequences that come with this: 24% of people not RTS at 1-7 years post-op cited fear of re-injury as their main reason.

-       Ongoing knee symptoms: 22% of people who haven’t RTP post op (1-7 years) cited poor knee function as their main reason

-       Lifestyle eg. too busy with work or family (shifting priorities): Approximately 10% of participants who haven’t RTP cited this as their main reason

-       Practicalities: Change to sporting team/coach, or moving to another geographical location

-       Choosing to exercise via other means eg. gym or cycling. These individuals may find their outcome to be successful despite not returning to pre-injury sport, but equally this raises the discussion around whether these individuals may have been able to pursue non-operative management in the first place.

 (Ardern, 2014)


Ardern et al’s (2014) study found that ‘Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity’. They also found that ‘Those who returned had more positive psychological responses, reported better knee function in sport and recreational activities, perceived a higher knee-related quality of life and were more satisfied with their current knee function’. Additionally, for every one extra ACL-RSI point there was approximately twice the odds of returning to pre-injury activity.

‘The factor most strongly associated with returning to the pre-injury activity was the ACL-RSI scale, which evaluates psychological readiness to return to sport and activity after ACLR’. ‘This could suggest that the most important factors influencing the decision to return may be related to the individual’s appraisal of their capacity to participate and the risks associated with participating.’ (Ardern et al, 2014).

With measures of subjective knee function- poor IKDC scores correlate with over 4x higher likelihood of failing (objective strength and control based) RTS tests. Contrary to this, 50% of athletes who scored well on IKDC overestimated their recovery ie. good subjective IKDC scores did not necessarily mean passing RTS tests (Logerstedt, 2014). With 22% of people citing poor knee function as their primary reason for not returning to sport- this highlights the importance of prescribing rehab comprehensively and progressively through until the individual obtains their highest level of possible function.

What does all of this tell us? In some cases, kinesiophobia and lack of confidence are justified.

Low function and kinesiophobia scores can accurately reflect impaired physical capacity and lack of comprehensive physical rehabilitation. In many cases- low ACL-RSI and low IKDC scores can be an appropriate psychological appraisal of insufficient knee ability and readiness for performance. For example, if an athlete feels/knows that they haven’t regained full strength, that their hopping isn’t very controlled, they have knee discomfort, or they feel that they don’t trust their knee when changing direction their lack of confidence might be very valid ie. they truly aren’t physically ready for these tasks (and indeed would have a high re-injury rate with activity participation) and return to sport. In which case to simply apply mental skills coaching to overcome their nervousness and get them into high level training may be dangerous and increase their risk of reinjury.

In other cases these scores can highlight a mismatch between pure psychological readiness and physical capability (physical >psychological readiness and vice versa).

Therefore, how do we know when kinesiophobia is justified? It’s here where the art needs to meet the science. Clinically, we use objective physical testing (strength, power, functional) alongside patient reported symptom scores (IKDC subjective) and measures of kinesiophobia (ACL-RSI) to see whether the results concur.

If an individual is physically safe and ready to progress but not mentally ready- we direct them towards specific mental skills coaches to work on confidence and sport-specific strategies. If however the athlete is lacking confidence but also lacking the physical requirements- we look at their physical rehab program and where they need extra attention eg. Quadriceps power, neuromuscular control, deceleration running training.  Ideally physical and mental outcome measures are applied at regular intervals throughout the rehab process to identify when the individual needs extra input or extra focus on particular realms. I think mental skills rehabilitation should be part of the post-operative program of most individuals and athletes in particular.

As Anna Rogacki (mental skills coach) writes below, expert mental skills coaching strategies in collaboration with expert physiotherapy allows the individual to optimize their rehab at each stage of the process. This teamwork also allows the individual to work on building confidence in their knee and their performance at a rate which doesn’t jeopardise their recovery by giving them a false sense of security, or hold them back at the pointy end of rehab. This combined approach should help reduce the likelihood of an individual failing to RTP for modifiable psychological reasons, and improve upon the RTP stats cited in Ardern’s work.


Anna Rogacki- mental skills coach:

‘An athlete's relationship to their body is perhaps the most important element of their ability to perform therefore it stands to reason that when this relationship is forced to deal with significant injury, it often has a tremendous physical impact as well as an emotional impact. Often overlooked, a key component missing from so many athlete's rehabilitation is mental rehabilitation. It is overlooked to the detriment of the athlete's full capacity to heal well and return to sport at peak.’

‘In the initial stages of injury an athlete must resourcefully deal with negative emotions that arise. Feelings of frustration, fear, anger and even grief are very common. Not dealing with these emotions can have a physical impact on recovery. Creating more tension in an already tense environment. The first steps I work on with athletes is clearing "space" to make sure we can build a powerful foundation to start the physical and mental rehabilitation process.  The most effective technique in my experience at this stage of the rehab process is contemplative meditation. Working on awareness of thoughts and feelings that will not serve the athlete in their rehab and making sure we deal appropriately with those thoughts and feelings.’

‘From that foundation we are then free to tackle the sometimes monotonous, frustrating and slow process of physical rehab. Staying focussed on the process of rehab and the progression of rehab. The end goal of returning to peak performance is great but focussing on how the athlete is going to achieve it and setting up measure and tracking systems to stay focussed on the present is my intention during the grind of early and middle stage rehab. Techniques such as Values based Goal Setting and Mental Imagery are key during this stage.’

 ‘Every stage of rehab builds on the previous stage. When the athlete is preparing to return to sport it is important to tune into fears/apprehension/overcompensation as well as being too eager to push above and beyond what the body is ready for. Concentrating on training the skills sets of Attention and Mind Body Connections during this stage is important for the what will be asked of the athlete when not only returning to sport but returning to peak. If we have built a rehab practice where the athlete has installed belief and certainty it makes the return to peak performance, in my experience, far smoother and successful than a practice that has not diligently taken care of the mentality of the athlete.’

 ‘Having the tools to cope and rise to the challenge of recovering from a significant injury and the athlete regaining/building a sense of control over their recovery and return to sport, I believe, is crucial. A wholistic approach to rehabilitation being facilitated by physiotherapists like Rhi and Jane are paving the way of integration and collaboration that completes the picture of mental and physical rehabilitation.’


 Ardern CL, Österberg A, Tagesson S, et al. Br J Sports Med 2014;48:1613–1619

Logerstedt, D., Di Stasi, S., and Grindem, H. (2014). JOSPT. Self-Reported Knee Function Can Identify Athletes Who Fail Return-to-Activity Criteria up to 1 Year After Anterior Cruciate Ligament Reconstruction: A Delaware-Oslo ACL Cohort Study. 44(12)

Anna Rogacki,




Part 2: Successful outcomes following ACL reconstruction

Re-injury risk and how to reduce it

One of the most important goals for an athlete following ACL reconstruction, and one of the main markers of a successful Return to Sport is prevention of reinjury. But how good are we at helping our patients achieve this goal? And how do we know when a player is at a suitably low risk to RTS?

 To answer this question we first need to understand the stats regarding reinjury risk and how this differs between populations.

Part 1: Successful outcomes following ACL reconstruction- Return to Sport

Part 1: Successful outcomes following ACL reconstruction- Return to Sport

This is the first blog in a 4 part series looking into successful outcomes following ACL injury.

An ACL injury is generally a stressful time for an individual. Upon seeking professional advice, some people decide that surgical ACL reconstruction is the best option for them whereas others decide to undertake conservative rehabilitation of their knee. Often, entering ACL reconstruction, individuals have a few goals and expectations in mind. These commonly include…

Introducing our new 4 part blog series……….. ACL reconstruction and rehabilitation: Are we successful?

 Introducing our new 4 part blog series……….. ACL reconstruction and rehabilitation: Are we successful?

Ardern et al’s (2016) consensus statement on Return to Sport (RTS) following ACL reconstruction notes that the goal of the athlete (along with other stakeholders eg, coach, club, medical team) is a successful ‘safe and timely’ return to sport.

This highlights the importance of balancing three key components

-Minimising time away from play

-Minimising reinjury risk

-Maximising sporting performance upon return to play

Article review- Filbay et al (2017) Delaying ACL reconstruction

Article review- Filbay et al (2017)  Delaying ACL reconstruction

Filbay et al (2017)

Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial.


5year follow up of a prospective RCT comparing 3 groups

1) Exercise therapy plus early ACLR    (Surgery within 10 weeks)-    62 people

2) Exercise therapy with delayed ACLR (Median 867 days to surgery)-  30 people 

3) Exercise therapy alone - 29 people

All participants (age 18-35, males 73%) had injured their ACL <4weeks ago; Excluded professional sports people and those less than moderately active.

Article review - Wellsandt et al (2017) - Limb Symmetry?

Article review - Wellsandt et al (2017) - Limb Symmetry?

Wellsandt et al (2017) Limb Symmetry Indexes Can Overestimate Knee Function After Anterior Cruciate Ligament Injury

Comparison between single leg hop and quad strength – in two different ways.

Who - Non professional cutting athletes, 14-55 yrs old(Excluded other significant injuries).

Limb Symmetry Index (LSI) = comparison between Left and Right during an assessment.

Estimated pre-injury capacity (EPIC) = measuring uninvolved limb pre-operatively then comparing to the involved side at 6 months post-op.

2016 Patellofemoral (Knee cap) consensus statements

2016 Patellofemoral (Knee cap) consensus statements

The International Patellofemoral Pain Research Group consists of expert clinicians and researchers who pool the best available current research on the topic of patellofemoral pain (PFP). The following is a summary of their 2016 consensus statement

Article Review - Frobell et al (2010)


Frobell et al (2010) - Early ACL Reco + Rehabilitation compared to  Rehabilitation +Delayed ACL Reco if required (2 and 5 year follow up)


  • 120 patients between -18-35 yrs  (Sub elite, recreational athletes) 
  • OUTCOME - Early ACLR and Rehab NOT superior to Rehab and Delayed ACLR (if required) at 2 and 5 years for KOOS (a questionnaire that compares pain, function in sport and recreation and knee related quality of life)  

Article Review - Kyritsis et al (2016)

Article Review - Kyritsis et al (2016)

Kyritsis et al (2016) Likelihood of ACL graft rupture: not meeting six clinical discharge criteria before return to sport is associated with a four times greater risk of rupture


  • For every 10% loss of HS/Quads ratio = 10.6 x likelihood of graft rupture  

  • This ratio is increased if quadriceps strength is not fully regained to pre operative level

  • Meeting the 6 criteria - 116 athletes Discharged (73%) – (12/116 had a graft rupture) =  10%