CAN YOU TEAR YOUR OTHER ACL AFTER

RETURNING TO PLAY FROM ACL REPAIR

SURGERY?

Research Team
Catherine Martin, ATS
Chaypin Buchanan,LAT, ATC- AT Advisor
Dennis Cobler, EhD, LAT, ATC-Faculty Advisor
Matt Harris, PT, ATC- Content Advisor in Physical Therapy

4/1/2018
 Table of Contents
CLINICAL SCENARIO... 3
Focused Clinical Question... 3
Keywords...4
SUMMARY OF SEARCH METHODOLOGY...4
Search Strategy...4
Sources of Evidence Searched...4
Best Evidence Reviewed...5
CLINICAL BOTTOM LINE...6
Implications for Clinical Practice...7
Recommendations for Future Research...7
REFERENCES... 8
CLINICAL SCENARIO
The problem arises when an athlete returns to play from ACL repair surgery and completes the
rehabilitation process and then will injure their contralateral or opposite ACL soon after. So the
issue is that can the type of rehabilitation affect the outcome of an individual or is it their fault
for tearing the other ACL?

Development of Clinical Question:

My last clinical question was also ACL related but it pertained to whether the athlete should
return to play with a brace or not. I had read some articles about ACL injuries and how it can be
very likely to tear the opposite ACL and even the same one. For research purposes, Chaypin and
I decided that it would be better for me to get into the research about injuring the opposite ACL
after returning to play from ACL repair rehabilitation and how the rehabilitation process could
cause contralateral injury to ACL. Also we have ideas about my next focus of research so that is
exciting too.

Development of Investigation Committee:

● Chaypin Buchanan- She is the designated athletic trainer for the E&H Women’s soccer
team. With three ACL tears within a month of each other this team had a good variety of
players who either wore an ACL brace or chose to not wear one.
● Dennis Cobler- Dr.Cobler is the head of the athletic training program as well as a
certified athletic trainer. We decided to select him based on his experience in the field as
well as an AT’s opinion vs. a PT’s opinion on whether or not to wear an ACL brace post
surgery.
● Matt Harris- He is a PT in Abingdon, VA and also a professor at Emory & Henry
College. He will be a huge help because of his experience in physical therapy.

Focused Clinical Question:

In post-surgical ACL patients, what are the effects of accelerated rehabilitation programs versus
traditional as it pertains to the contralateral ACL after return to play?

Keywords:
I used contralateral ACL, rehab plans, functional testing, and avoiding contralateral ACL injury.

SUMMARY OF SEARCH METHODOLOGY

I started with searching about patients tearing their contralateral ACL and then found some info
on ipsilateral ACL injuries that lead me to some information that I benefited from. I then
searched rehab plans for ACL and that helped me some with one article but not much. The
phrase that helped me the most was contralateral ACL injuries. I did have trouble choosing
which articles were important for my research and collaborated a little with my group for help. I
did realize that there is not much research done on contralateral ACL injuries and we do not have
a clear idea of the cause and if rehab plans from previous injury have a part in the new injury.

Search Strategy:
I used PICO to format our clinical question. P is patient population or clinical problem and my
patient population is post surgical ACL tear patients and the clinical problem is if type of rehab
can cause the patient to tear their other ACl after they have returned to activity . I is the
intervention of interest and mine is mixing my interest with acl healing and return to play
criteria along with rehab. C is comparison of interventions and mine is traditional rehab versus
high intensity rehab. O is outcome of interest and my outcome is which is better when it comes to
rehab. If traditional or accelerated rehab can avoid tearing your other ACL after being cleared
for activity.

Sources of Evidence Searched:

Medline Complete, Academic Search Complete

Best Evidence Reviewed:

1. Risk of Secondary injury in Younger Athletes After Anterior Cruciate Ligament
Reconstruction. BY: Wiggins, Amelia J. Grandhi, Ravi. Schneider, Daniel. Stanfield,
Denver. Webster, Kate. Myer, Gregory D. Source:
American Journal of Sports Medicine. Jul2016, Vol. 44 Issue 7, p1861-1876. 16p.
This source says “...nearly 1 in 4 young athletic patients who sustain an ACL injury and
return to high-risk sport will go on to sustain another ACL injury at some point in their
career, and they will likely sustain it early in the return-to-play period”. This source
discusses the rehab process briefly and also notes that returning to a physically
demanding sport can increase the risk of tearing the same or opposite ACL. It does talk
about rehab in some aspect as it notes neuromuscular control training and improved
rehabilitation. My interpretation of the improved part of the phrase meant to me that they
were using accelerated rehab to help with returning to a demanding sport.
2. Low- Versus High-Intensity Plyometric Exercise During Rehabilitation After Anterior
Cruciate Ligament Reconstruction. BY: Chmielewski, Terese. George, Steven. Tillman,
Susan. Moser, Michael. Lentz, Trevor. Indelicato, Peter. Trumble, Troy. Shuster,
Jonathan. Cicuttini, Flavia. Leeuwenburgh, Christiaan. Source: American Journal of
Sports Medicine. Mar2016, Vol. 44 Issue 3, p609-617. 9p.
This source says “Across both groups, plyometric exercise induced positive changes in
knee function, knee impairments, and psychosocial status that would support the return to
sports participation after ACL reconstruction”. The thing with this one is that they did not
conclude anything. This said that there needed to be more information to see if high
intensity plyometrics would hurt or help ACL tears after returning to activity.
Plyometrics come in the rehab process during the maturation phase of healing most of the
time so it may not be detrimental in the first place because it is later on in the healing
process.
3. ACL-injured soccer players see high knee injury rate after rehab BY: Lori Rochelle
Roniger Source: Roniger, Lori Rochelle. Source: "ACL-injured soccer players see high
knee injury rate after rehab." Biomechanics, 1 Mar. 2006, p. 9. General OneFile,
http://link.galegroup.com/apps/doc/A144021723/ITOF?u=vic_ehc&sid=ITOF&xid=a56d
3ee8. Accessed 8 Apr. 2018. This source that I found discussed swedish soccer players
that has returned to play from ACL reconstruction and how they had a larger risk for
inuring both legs. Most of the athletes suffered overuse injuries but some suffered
traumatic injury to their other leg. While this article did not address the type of
rehabilitation, it did address the time span for an athlete returning to play. They only had
one athlete with an ACL injury to the opposite leg however. They mentioned that most
people think that after surgery and then six months and the athletes would be perfect to
go. This is not true. This article helps support the side of not using accelerated
rehabilitation. When we put athletes through functional rehab before they can return to
 play, we should probably consider making the activities more challenging and more game
like to avoid the shock to the knees after the athletes return to competition.
4. Incidence of Second Anterior Cruciate Ligament Tears BY: Schilaty, Nathan. Bates,
Nathaniel. Hewett, Timothy. Krych, Aaron. Stuart, Michael. Sanders, Thomas. Source:
American Journal of Sports Medicine. Jun2017, Vol. 45 Issue 7, p1567-1573. 7p. “The
incidence of second ACL tears in this population-based cohort was 6.0%, with 66.7% of
these tears occurring on the contralateral side from the original injury”. This source
wanted to see the correlation of contralateral injuries to the knee after returning to
activity. The thing that I do not love about this is that it is from one area of the world, just
Minnesota. What I liked is that they picked patients by isolated ACL tears and the data
from grabbed from 10 years. This article did not address the rehab type but did give me
some data for contralateral injury to the ACL.
5. Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACL
Reconstruction BY: Kaeding, Christopher. Pedroza, Angela. Reinke, Emily. Huston,
Laura. Spindler, Kurt. Source: American Journal of Sports Medicine. Jul2015, Vol. 43
Issue 7, p1583-1590. 8p. This article wanted to identify the risk factors for secondary
ACL injuries. They had patients that were in many situations. This meant that they had
young and older patients that were involved in demanding activity and ones that are do
not participate in a lot of activity. This article helped me with my research because of the
fact that it gives a more specific target to the individuals that experience contralateral
ACL injuries. So with their research I now know that contralateral ACL tears most likely
are to happen to younger individuals that are involved in higher activity. The data they
had on ipsilateral ACL tears stated that younger adults that participate in higher levels of
activity and it also matters what type of graft that had that can lead to failure.
6. Return to sport: Does excellent 6-month strength and function following ACL
reconstruction predict midterm outcomes? BY: Sousa PL;Krych AJ; Cates RA;
Levy BA;Stuart MJ;Dahm DL. Source: Knee Surgery, Sports Traumatology,
Arthroscopy: Official Journal Of The ESSKA [Knee Surg Sports Traumatol Arthrosc]
2017 May; Vol. 25 (5), pp. 1356-1363. Date of Electronic Publication: 2015 Jul 24. This
research article had their patients go through isokinetic testing and functional testing done
6 months following their surgery. In the end, they found that individuals that had really
good scores from their 6 month testing and went back into higher level activity, have a
much greater risk for contralateral ACL injury. They could not note if it was activity level
related or something else related. They did however mention that testing and giving
return to play release to someone should be warned about the risk of contralateral ACL
injury with a higher activity level.
CLINICAL BOTTOM LINE
Based on my research, there is not an answer at this time specifically. From my interpretation,
the studies that I found hint at high level of activity being the cause for contralateral tear. To me,
this means that they followed a specific or traditional protocol for the ACL healing of the
patients. This meant that they probably only worried about the injured ACL during the rehab and
during the testing. So with people that follow traditional rehab can be susceptible to a
contralateral ACL injury because of the fact that they have not been really forcing their uninjured
knee to be challenged as much as the other. During the rehab process, we worry about getting
that leg back to proper strength and mechanics and other things but we really do not consider that
we tend to neglect the other knee. When we neglect the other knee, we forget that patients will
tend to rely on their uninjured leg following an injury when that leg is probably not used to
taking all of the weight or pressure which can lead to the contralateral injury. I did not get a lot
of research on accelerated rehab programs so there still needs to be some research to have data
on that to see whether traditional rehab and timeline is better or worse that an accelerated rehab
program.

​Implications for Clinical Practice

My evidence did not suggest whether traditional or accelerated rehab was prefered or prevented
contralateral ACL injury. I did find that younger people that return to more demanding or to a
higher level of activity are at risk to have a contralateral ACL injury. I only had one source that
mentioned talking to the patients about the risk and educating them. I was not surprised to see the
results of contralateral injuries that correlate with high level activities because not all rehab
programs actually push the person to be at the point of actually being ready to return before they
release the patient. I think that most people that facilitate the rehabs for patients focus on the time
frame when it comes to being ready to return. As an athletic training student, I have seen many
athletes that say and think that at a certain time, they will be ready to return to play. I think that
we need to educate our patients that time is not the only requirement to healing. The rehab that
they participate in has to be done properly for the increase of strength, endurance, power,
balance, and other things. Also something that should be considered, is that one source did think
that the use of plyometrics in a rehab can help some with returning to activity because it pushes
the patient to become more comfortable and also learn how to land on their healing knee. But we
also have to consider the things that are before the maturation stage of healing which is more
functional. There needs to be more research done to really determine which rehab is better or
worse.
Recommendations for Future Research
To this day there has not been much research on what really causes contralateral ACL injuries
when it comes to rehab. When I committed to this question, I thought that there would be more
information on this topic but there was not. I recommend that there be more research done to get
data on if the rehab process is the biggest problem that causes contralateral ACL injuries. It
would be great to have data on that as well as what a rehab program that could lower the amount
of contralateral ACL injuries.

REFERENCES:
"ACL-injured soccer players see high knee injury rate after rehab." Biomechanics, 1 Mar. 2006,
p. 9. General OneFile,
http://link.galegroup.com/apps/doc/A144021723/ITOF?u=vic_ehc&sid=ITOF&xid=a56d3ee8.
Accessed 8 Apr. 2018.

American Journal of Sports Medicine. Jul2015, Vol. 43 Issue 7, p1583-1590. 8p.

American Journal of Sports Medicine. Mar2016, Vol. 44 Issue 3, p609-617. 9p.

American Journal of Sports Medicine. Jul2016, Vol. 44 Issue 7, p1861-1876. 16p.

American Journal of Sports Medicine. Jun2017, Vol. 45 Issue 7, p1567-1573. 7p.

Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal Of The ESSKA [Knee Surg
Sports Traumatol Arthrosc] 2017 May; Vol. 25 (5), pp. 1356-1363.