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Post-Surgical Management of Sports Players

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1. Immediate Post-Operative Care (Day 0 - Week 1)

Pain Management

• Local anesthetic (with liposomal bupivacaine considered for extended relief) liberally applied at the surgical site
• Multimodal analgesia: Acetaminophen + NSAIDs + ice to minimise opioid use
• Adductor canal block (purely sensory) preferred over femoral nerve motor block after knee surgery - provides equivalent pain relief with faster quadriceps strength recovery

Wound & Limb Care

• Cryotherapy (ice bags) used liberally for swelling and comfort; note that evidence for reducing hospital stay or improving ROM is limited
• Elevation of the operated limb
• Compression dressings as needed
• Early mobilisation (partial weight bearing with crutches is allowed immediately after isolated ACL reconstruction)

Bracing

• Knee immobilisation in a fully extended brace started immediately after ACL surgery - prevents flexion contracture and protects the weakened quadriceps, while still allowing flexion
• Continuous passive motion (CPM) machines are NOT used routinely - literature does not support added benefit

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2. Early Rehabilitation Phase (Weeks 1-4)

Range of Motion

• Active and passive knee extension with heel elevated and knee supported posteriorly
• Progressive restoration of full flexion as tolerated
• Early intensive rehabilitation prevents arthrofibrosis and restores strength sooner

Weight Bearing & Ambulation

• Crutches typically discontinued by 3 to 4 weeks post-operatively
• Weight-bearing status may be modified if concurrent meniscal repair or articular cartilage procedures were performed

Strengthening - Phase 1

• Quadriceps sets and straight-leg raises - do not stress the graft
• Early hamstring emphasis - hamstrings act in concert with the ACL to prevent anterior tibial translation
• Blood flow restriction (BFR) training: An air tourniquet is placed proximally on the limb during low-intensity exercises - promotes muscular hypertrophy/attenuates atrophy. Works via recruitment of fast-twitch fibres in hypoxia + catecholamine/growth hormone stimulation (similar to heavy conventional exercise)

Neuromuscular / Proprioceptive Training

• Instituted within the first 2 weeks
• Neuromuscular training improves knee function and pain reduction
• Strength training improves hamstring recovery
• Post-op program should combine both modalities

Electrical Muscle Stimulation (EMS)

• Does NOT significantly decrease muscle atrophy after ACL surgery
• No long-term strengthening benefit
• May be used sparingly for muscle re-education in patients with poor quadriceps activation

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3. Progressive Strengthening Phase (Weeks 4-8)

Exercise Progression

Core Muscle Injury / Sports Hernia Protocol (Fischer's, Table 225.4)

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4. Return to Sport (RTS) Criteria

Objective Functional Tests

• Hop testing is the key functional measure:
  • Single-leg hop for distance
  • Single-leg triple hop for distance
  • Single-leg timed hop
  • Single-leg crossover hop for distance
  • Vertical jump test
• A Limb Symmetry Index (LSI) score of ≥85% compared to the normal limb is required for release to RTS

Strength Criteria

• Minimum 80% return of thigh (quadriceps and hamstring) strength
• Ability to perform sport-specific agility tasks

Timeline

• Return to sport should be delayed at least 6 months after ACL reconstruction to allow graft maturation
• Animal studies suggest the graft should be spared significant loads for 6 to 12 months
• Early return to high-level sport is a significant risk factor for ACL graft failure
• Graft maturation may continue up to 18 months post-op
• For core muscle injuries: RTS generally within 5-8 weeks, longer for bilateral repairs or adductor procedures

Key Statistics (Campbell's, 2026)

• Only 44% of patients returned to competitive sport despite 90% having normal/near-normal outcome scores - highlighting the gap between functional recovery and actual RTS

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5. Adjunct Considerations

Home vs Clinic Rehabilitation

• Home-based programs shown to be equally effective and score higher on quality-of-life measures
• However, evidence comes largely from recreational athletes, not high-level competitive athletes - supervised programs are still preferred at elite level

Functional Bracing

• Controversial after ACL surgery
• Some data suggest benefit for in vivo knee kinematics and graft protection
• Limited evidence supports routine brace use to reduce reinjury rates
• May be considered for collision sports (football, rugby, etc.)

Psychological Readiness

• Fear of reinjury is a major barrier to RTS; psychological readiness assessment (e.g., ACL-RSI score) should accompany functional testing

Minimally Invasive Surgery Advantage

• Laparoscopic repairs (TEP/TAPP) for core muscle injuries show >90% return to sport in <1 month in multiple series - faster than open repair for early recovery, though long-term outcomes are comparable (Fischer's Mastery of Surgery)

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6. Complications to Watch For

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• Campbell's Operative Orthopaedics, 15th Ed (2026), Chapter 50 - [ACL Rehabilitation Protocol] - Knee Surgery, p. 2722-2723
• Fischer's Mastery of Surgery, 8th Ed - Chapter 225: Athletic Pubalgia/Core Muscle Injury - Postoperative Rehabilitation, p. 6138-6139
• Recent systematic review: Prehabilitation before ACL reconstruction (PMID: 40276858, Knee Surg Sports Traumatol Arthrosc, 2025) confirms short- and long-term benefits of structured pre/post-op rehab
• Open kinetic chain exercises in early ACL rehab (PMID: 39985872, Phys Ther Sport, 2025) - meta-analysis showing safety and benefit when introduced appropriately

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Latest RTS Testing Protocols & Prognostic Factors in Return-to-Play Studies

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Overview: The RTS Decision Framework

1. Return to participation - cleared to train non-competitively
2. Return to sport - training at full intensity
3. Return to performance - competing at pre-injury level

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1. Lower Extremity RTS Testing Protocols

A. Knee / ACL (Most Evidence-Dense Area)

• 85% of RTS literature focuses on knee pathology; 82% specifically on ACL reconstruction
• No uniform/standardised RTS criteria exist for any lower extremity joint

Strength Testing

Hop Testing Battery (Functional Performance)

B. Soccer / Football Muscle Injuries

• Strength symmetry: between-limb knee flexor/extensor strength symmetry (most cited)
• No pain during soccer-specific actions
• Range of motion tests: Active Knee Extension (AKE), passive/active straight leg raise, Askling-H test (highest certainty)
• Subjective readiness assessment
• Completing at least one full team training session

• Pain assessment during adductor-loaded movements
• Completing at least one full team training session
• Restoring strength levels
• Hip adductor squeeze test normalisation

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2. Upper Extremity RTS Testing

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3. Prognostic Factors for RTS After ACL Reconstruction

Positive Prognostic Factors (favour RTS)

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4. Psychological Readiness - The Emerging Priority

• ACL-RSI scale: effect size 1.55 (95% CI: 1.24-1.87) - the most effective predictor of RTS success
• Hop tests and LSI were only moderately effective
• Flexion-LSI was least effective
• Recommendation: adopt a multi-dimensional approach integrating both psychological and physical assessments

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5. Practitioner Decision-Making in RTP (Real-World Gap)

• Surgeons (47% of studies): rely predominantly on injury and post-operative timelines
• Physiotherapists: prioritise functional assessment and strength (≥50%)
• MDTs: more likely to include psychological readiness (50%) and sport-specific testing (38.5%)
• Only 20% of studies referenced formal RTP frameworks or guidelines
• Athlete-centred shared decision-making is the recommended approach
• Biggest influencing factors: type of sport and athlete's ambition (cited in 26.4% of all studies)

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6. Recommended Multi-Dimensional RTS Test Battery (Current Evidence Synthesis)

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7. Key Evidence Gaps & Research Needs

1. No standardised criteria exist for ankle, hip, or upper extremity RTS - almost all evidence is ACL/knee-centric
2. LSI 85% threshold is questionable: healthy individuals regularly fail, suggesting the threshold needs recalibration by sport, sex, and age
3. Functional tests (hop, strength) have poor predictive validity in isolation - only multimodal batteries reduce reinjury risk
4. Prognostic models have moderate accuracy (~70%) - insufficient to replace clinical judgement
5. Pediatric and female athlete populations are under-studied in RTS testing literature
6. Long-term outcomes beyond 12 months post-RTS are rarely tracked

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Summary of Key Papers

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Post-Operative Rehabilitation: Phase-Wise Exercise Protocols

SHOULDER & KNEE - Campbell's Operative Orthopaedics, 15th Ed (2026)

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PART 1 - KNEE: ACL Reconstruction Rehabilitation

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STAGE I: 0 - 2 Weeks (Protection & Early Motion)

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STAGE II: 2 - 4 Weeks (Progressive Loading)

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STAGE II: 4 - 6 Weeks (Closed-Chain Progression)

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STAGE II: 8 - 10 Weeks (Dynamic Training Begins)

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STAGE III: 12 - 16 Weeks (Strength & Full ROM)

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STAGE IV: 16 - 20 Weeks (Plyometrics & Jogging)

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STAGE V: 20 - 36 Weeks (Sport-Specific Training)

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STAGE VI: Return to Sport (36 Weeks)

• Motion >130°
• Hamstrings >90% symmetry
• Quadriceps >85% symmetry
• Sport-specific agility testing passed
• Maintenance exercises 2-3×/week ongoing

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PART 2 - SHOULDER REHABILITATION

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2A. ROTATOR CUFF REPAIR - Minor Tear (<2 cm)

PHASE I - Protection & PROM (Weeks 1-6)

• Sling at all times for 3 weeks, then as needed for comfort
• Sutures removed at 7-10 days
• Pendulum exercises
• AROM wrist and hand
• HEP 2-3×/day

• PROM ≥150° FL | PROM ≥65° ER | PROM ≥160° scaption
• Able to comb hair (dominant arm) | Open/close car door
• Lifting ≤1 lb

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PHASE II - Progressive AROM & Strengthening (Weeks 7-10)

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PHASE III - Advanced Strengthening & Return to Sport (Weeks 11-16)

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2B. ROTATOR CUFF REPAIR - Moderate Tear (2-5 cm)

Key Differences vs Minor Tear:

• Wean from sling
• Initiate true ABD stretch and IR without overpressure
• AROM <90° (at 6 weeks)
• Supine TheraBand ER stretch (as needed)
• Cane exercises supine - FL, scaption, ER neutral, ER in 90° scaption

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2C. BANKART REPAIR (Labral/Instability Repair)

PREOPERATIVE GOALS:

1. Independent with post-op exercise program
2. Independent with preoperative strengthening (isometrics + isotonics in pain-free, stable range)

PHASE I - Weeks 1-2

PHASE I - Weeks 3-4 (PT 4×/week begins ~day 15)

PHASE I - Weeks 5-6 (PT 4×-3×/week)

PHASE II - Weeks 7-8 (Goals by 8 weeks)

PHASE II - Weeks 9-12 (PT 1×/2-3 weeks)

PHASE III - Weeks 11-16 (Sport Return)

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2D. Shoulder Arthroplasty (TSA/RSA) Protocol

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Summary Comparison: Phase Progression at a Glance

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