The ACL reconstruction surgery may be the most famous orthopedic surgery out there. Not because of the technical skill required, but for the career impact it has on the athlete who suffers an ACL tear. The surgery might take 1 hour, but the rehab timeline is measured in months. What’s worse, only about 50% of athletes get back to pre-injury levels of sports performance following the surgery.
The Biology of an ACL Graft
So if something has a 50% success rate, why is it so trusted by million dollar athletes? The secret is in the details. First we need to break down what is happening with the biology. The ACL graft is like a scaffold for your body to grow new tissue onto. It usually takes about 2 months for this to happen. In that time your body is in healing mode, which means swelling.
Swelling is great. It bring nutrients the body needs to heal. It has a downside however, in that it inhibits your quadriceps muscle from activating fully. This is why good rehab always calls for early and often quadriceps activation exercises to reduce the loss of quadriceps strength during the healing phase. So then after about 3 months you are left with an intact ACL (although still fragile) and a quad that is functional enough to walk and squat down to get something from the floor. Sadly, this is also about the time that most insurance plans stop covering physical therapy.
“Do I Have Enough Visits On My Plan To Cover ACL Rehab?”
What to do? There are multiple strategies that good therapists have developed over the years to get around this.
First is to underutilize at the beginning of rehab. Therapists will send their patient home with a home program and hope for the best at the once/week follow up. Then when it comes to training for return to sport they will hopefully have enough visits to get a check in every 2-3 weeks as the quad strength slowly builds to pre-injury levels.
The other, less helpful strategy is to happily see the patient 3x/week for each week post-op. This runs through their available visits right about the time when they need to start sports rehab. This is far too common and likely is a major factor in the low return to sport rate mentioned earlier in the article.
White Glove Care vs. Reality
Those athletes I mentioned don’t need to worry about this. They get the appropriate post-operative care, but they also get high level cutting, jumping, rotational, and power training necessary to prevent re-injury. They get the same level of care throughout the 8-12 long months it takes for the leg to not just regrow high-level strength, but to re-teach the leg how to react in the split-second world of sport.
It’s a sad state of affairs that rehab for one of the most popular orthopedic surgeries in the US is not even close to fully covered by almost every insurance plan. I’ve been on a dozen calls with insurance companies where I’ve been told the plan doesn’t pay for the patient to get back to sports, only daily life. This is just not good enough.
Now obviously as an out-of-network provider I’d love to say “just give me cash for all 30+ sessions you really need to get back to your sport.” Great for the pros, but that’s a massive financial commitment that all but a few can make. I do however see a good path forward through teamwork either within or between practices.
Ensure You Get Comprehensive ACL Rehab You Can Afford
The fix: do both. The best possible outcomes in our current healthcare system for patients with an ACL reconstruction will come from a collaborative approach between sub-acute injury care at a (good) in-network physical therapy office. This should be followed by a rigorous return to sport program led by a performance therapist once the benefits are expired.
In-network clinics are set up well for the first stages of ACL recovery. They can get you the basics for range of motion, electric stimulation to get the quad activating, and starting you back to daily life after a surgery. For the athlete who truly wants a full return to sport, the logical next step would be to find a therapist who knows how to handle to complexities of a post-surgical case in the context of high performance and sport-specific training.
This involves more than just a weight rack and some medicine balls in the corner of your local clinic. Sports therapy relies on simulating the environment of the athlete as much as possible. Sports therapists have specific tools and training methods that will ensure the closest possible simulation to when that first whistle blows on your return.
Personal training lacks the guidance for reactive training, proprioception, and full-body problem solving that a physical therapist is trained to provide. Most out-of-network therapists will be able to work on a plan with you to keep the appropriate level of guidance without breaking the bank.
Conclusion
It’s a sad state of affairs when insurance companies (and sadly some orthopedic surgeons) see ACL rehab as a simple task. But for the athlete trying to get back to the field of play – and stay there – a more comprehensive approach is the only way to go.
Owen Campbell, PT, DPT, OCS
