Infographic
Br J Sports Med: first published as 10.1136/bjsports-2020-102273 on 27 January 2021. Downloaded from http://bjsm.bmj.com/ on October 4, 2021 at PUC-RS PO Box 750. Protected by
Infographic. ACL injury journey: an education aid
Connor Patrick Gleadhill ‍ ‍,1 Christian J Barton ‍ ‍2,3
PART 1—YOUR ACL JOURNEY GUIDE:
TREATMENT DECISION
After an anterior cruciate ligament (ACL)
injury, patients report feeling angry,
depressed, frustrated and uncertain about
their future.1 It is recommended that
patients and practitioners engage in shared
decision-­making to ensure an informed
choice about treatment is reached.2 Unfor-
tunately, there are limited resources to
help patients navigate treatment decisions
and set expectations following an ACL
injury. We coproduced an infographic (see
figures 1 and 2), with input from patients
about content and design, to present the
best available evidence in an easy to digest
format. This infographic (separated into
two parts) is an education aid, designed
Gleadhill CP, Barton CJ. Br J Sports Med June 2021 Vol 55 No 12
to be used with a health professional, to
reduce uncertainty, enhance communica-
tion and assist in shared decision-­making.
Broadly, it aims to cover:
INFORMATION TO DECIDE WHETHER TO
HAVE SURGERY (OR NOT)
Patients need a clear appraisal of the
evidence, to make an informed decision
about whether to have ACL reconstruc-
tion (ACLR) or not following ACL injury.2
There is only one published randomised
trial comparing the two options; it
reported no difference in pain, function or
return to preinjury activity levels at 1-­year,
2-­year and 5-­year follow-­up.3 Current
evidence suggests that the long-­ term
prevalence of osteoarthritis is no differ-
ence between patients who receive ACLR
compared with those who do not undergo
surgery.4 Although factors like a patient’s
age and plans to return to sports involving
pivoting may predict success of surgery,2
there are individuals who can cope
without ACLR after ACL injury.3 4
PART 2—YOUR ACL JOURNEY GUIDE:
REHABILITATION EXPLAINED
The need to ensure quality rehabilitation
Regardless of treatment pathway, patients
should focus on evidence-­based rehabili-
tation immediately after their ACL injury
as their firstline treatment.2 Rehabilitation
is key to restoring normal knee function,
preventing further knee injury and opti-
mising long-­term quality of life.2 Patients
should progress through an individualised,
criterion-­based programme with through
three distinct ‘phases’.5 Patients with
better functional performance have better
long-­term outcomes, including lower
rates of osteoarthritis.6 Intense rehabili-
copyright.
tation is important to optimise outcomes
as currently very few patients manage to
reach the standard required to return to
sport safely.7 8
When to return to play
During the final stage of rehabiliation,
patients face another complex deci-
sion—when are they ready to return to
sport? 56% of patients do not return to
competitive sport after an ACL injury.9 It
is recommended that patients wait at least
9 months before returning to sport after
ACLR.1 But we are uncertain about the
evidence surrounding the optimal time-
frame to return to play in non-­surgically
managed ACL injuries. Return to sport
should include sport-­specific training and
underpinned by a battery of performance
tests, for example, hop tests.1 5 It is also
important that patients feel confident to
return to sport before actually returning.1
How to reduce the likelihood of injury
Exercise-­
based injury reduction
programmes can reduce the incidence
of ACL injuries, but implementation is
inconsistent at community level.10 Part of
the challenge is choosing between many
options and optimising specificity for
chosen sports.10 However, there are a few
key components of effective programmes,
including regular strengthening and
   697
 Infographic
neuromuscular challenges like landing
and agility practice.10 Clinicians, coaches,
patients and parents should understand
and communicate the importance of adher-
ence to injury reduction programmes.
1 rehabilitation. Br J Sports Med 2015;49:1425.
School of Medicine and Public Health, The University of
Newcastle, Callaghan, New South Wales, Australia
2 cleared for sports participation after anterior cruciate
La Trobe Sport and Exercise Medicine Research Centre,
College of Science, Health and Engineering, La Trobe
University, Melbourne, Victoria, Australia
3 Orthop Sports Phys Ther 2017;47:825–33.
Complete Sports Care, Hawthorn, Victoria, Australia
Correspondence to Connor Patrick Gleadhill, School
of Medicine and Public Health, The University of
Newcastle, Callaghan NSW 2308, Australia;
​connor.​gleadhill@u​ on.​edu.a​ u
Twitter Connor Patrick Gleadhill @CGleadhill and
Christian J Barton @DrChrisBarton
Acknowledgements The authors would like to thank
the patients that helped contribute to the development
of this infographic.
698
Contributors CPG designed the concept for and
layout of the infographics, with input from CJB. The
infographic was then coproduced with a sample of
patients with ACL to optimise patient involvement.
Both authors approved the final version. CPG and
CJB drafted and finalised the accompanying editorial.
Both authors approved the final infographics and
accompanying text.
Funding The authors have not declared a specific
grant for this research from any funding agency in the
public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Supplemental material This content has been
supplied by the author(s). It has not been vetted by
BMJ Publishing Group Limited (BMJ) and may not have
been peer-­reviewed. Any opinions or recommendations
discussed are solely those of the author(s) and are
not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the
content. Where the content includes any translated
Gleadhill CP, Barton CJ. Br J Sports Med June 2021 Vol 55 No 12
Br J Sports Med: first published as 10.1136/bjsports-2020-102273 on 27 January 2021. Downloaded from http://bjsm.bmj.com/ on October 4, 2021 at PUC-RS PO Box 750. Protected by
material, BMJ does not warrant the accuracy and
reliability of the translations (including but not limited
to local regulations, clinical guidelines, terminology,
drug names and drug dosages), and is not responsible
for any error and/or omissions arising from translation
and adaptation or otherwise.
© Author(s) (or their employer(s)) 2021. No commercial
re-­use. See rights and permissions. Published by BMJ.
►► Additional material is published online only. To
view please visit the journal online (http://​dx.​doi.​org/​
10.​1136/​bjsports-​2020-​102273).
To cite Gleadhill CP, Barton CJ. Br J Sports Med
2021;55:697–698.
Accepted 29 November 2020
Published Online First 27 January 2021
Br J Sports Med 2021;55:697–698.
doi:10.1136/bjsports-2020-102273
ORCID iDs
Connor Patrick Gleadhill http://​orcid.​org/​0000-​0002-​
9448-​6237
Christian J Barton http://​orcid.​org/​0000-​0002-​2489-​
5350
REFERENCES
1 Ardern CL, Kvist J, Webster KE. Psychological aspects
of anterior cruciate ligament injuries. Oper Tech Sports
Med 2016;24:77–83.
2 Filbay SR, Grindem H. Evidence-­Based
recommendations for the management of anterior
copyright.
cruciate ligament (ACL) rupture. Best Pract Res Clin
Rheumatol 2019;33:33–47.
3 Frobell RB, Roos HP, Roos EM, et al. Treatment for
acute anterior cruciate ligament tear: five year
outcome of randomised trial. BMJ 2013;346:f232.
4 Chalmers PN, Mall NA, Moric M, et al. Does ACL
reconstruction alter natural history; a systematic
literature review of long-­term outcomes. J Bone Joint
Surg Am 2014;96A:292–300.
5 van Melick N, van Cingel REH, Brooijmans F, et al.
Evidence-­Based clinical practice update: practice
guidelines for anterior cruciate ligament rehabilitation
based on a systematic review and multidisciplinary
consensus. Br J Sports Med 2016;50:1506–15.
6 Pinczewski LA, Lyman J, Salmon LJ, et al. A 10-­
year comparison of anterior cruciate ligament
reconstructions with hamstring tendon and Patellar
tendon autograft: a controlled, prospective trial. Am J
Sports Med 2007;35:564–74.
7 Grindem H, Risberg MA, Eitzen I. Two factors that
may underpin outstanding outcomes after ACL
8 Toole AR, Ithurburn MP, Rauh MJ, et al. Young athletes
ligament reconstruction: how many actually meet
recommended return-­to-­sport criterion cutoffs? J
9 Ardern CL, Webster KE, Taylor NF, et al. Return to sport
following anterior cruciate ligament reconstruction
surgery: a systematic review and meta-­analysis of the
state of play. Br J Sports Med 2011;45:596–606.
10 Arundale AJH, Bizzini M, Giordano A, et al. Exercise-­
based knee and anterior cruciate ligament injury
prevention clinical practice guidelines linked to the
International classification of functioning, disability
and health from the Academy of orthopaedic physical
therapy and the American Academy of sports physical
therapy. J Orthop Sports Phys Ther 2018;48:1–42.
 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

THE ACL INJURY JOURNEY

This blog accompanies two infographics, published in the British Journal of Sports Medicine,
presenting the best available, and designed with input from people who have experienced ACL
injury. Both authors of the infographics are clinicians and researchers who work with many
people of all ages and levels of sport after ACL injury. These infographics are designed to be
used with your health professional, and help guide your decisions and rehabilitation process.

Part 1: Treatment decision

Gathering your rehab team
After an ACL injury, it is common to feel angry, depressed, frustrated and uncertain about your
future (1). First, you should gather members of your rehab team to help you make decisions,
guide your rehabilitation and keep you motivated. Members of your team can include exercise
professionals (e.g. physiotherapist), a surgeon, a sports doctor, your coach, team-mates, your
family, and your friends.

Starting rehabilitation straight away

You should begin high-quality rehabilitation immediately after an ACL injury (2). Most experts
agree that after your ACL injury, the best course of action is to try to return normal knee function
and delay the decision about whether to have surgery or not until after a period of rehabilitation
(3).

Deciding whether to have surgery (or not)

Younger, more active patients are more likely to re-injure their knee but this is probably
unrelated to whether you have surgery or not (4, 5). Returning to high level pivoting sports is
associated with more risk than running in straight lines, for example. Having other knee injuries,
like meniscal tears, at the same time as your ACL injury is associated with worse outcomes but
again the choice about surgery doesn’t seem to impact this outcome (6, 7). However, some
injuries may need to be repaired and this will be an individual decision. It is important to discuss
factors like your age, other injuries and your plans to return to high level pivoting sports because
you can talk with your rehabilitation team how to reduce your future injury risk (8). Remaining
happy, healthy and active is a key consideration for anyone following ACL injury and this may or
may not involve surgery.

There is no clear evidence that surgery is superior to undertaking high quality rehabilitation
alone. There is only one published randomised trial comparing the two options (9). This reported
no difference in pain, function or return to pre-injury activity levels at 1-, 2- and 5-years after an
ACL injury (9). Current evidence suggests that, in the long-term, there is no difference in how
many people develop osteoarthritis between people who have their ACL surgically
reconstructed and people who don’t have surgery (10). It is clear that some people can cope
without surgery following an ACL injury (9,10). Some people may even be able to return to high
level pivoting sports without an ACL reconstruction (11). We recommend you think about the
following things when talking to your rehab team and making your decision:
- Do I have all the information?

Gleadhill CP, Barton CJ. Br J Sports Med 2021;0:1–2. doi: 10.1136/bjsports-2020-102273

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

- What are my goals?

- What are my values? (Time with kids, playing with friends)
- What are the risk versus rewards for having surgery now?
- Am I being listened to?
- Have I been given enough time to make this decision?

Part 2: Rehab Explained

Working hard on your rehabilitation
Whether you have surgery or not, completing quality rehabilitation is the key to restoring normal
knee function, preventing further knee injury and optimising your long-term quality of life (2).
You should progress through an individualised, criterion based program, involving 3 distinct
‘phases’ (early, mid and late) (12). Exercises you can think about performing in these stages are
as follows (remember to perform these exercises with the guidance of a health professional):
● Early:
○ Exercises to straighten and bend the knee like using your front leg muscles to
straighten the knee and an exercise bike to improve your bending.
○ Exercises to strengthen your front leg muscles like leg extensions.
○ Practising weight bearing and walking evenly on both sides.
● Middle:
○ Exercises to improve your single leg balance and control (like standing on one
leg or standing on one leg on an uneven surface)
○ Exercises to improve your general leg strength with squats, lunges, and deadlifts.
○ Exercises to improve your single leg strength with single leg extension, single leg
squats.
○ Practising running.
● Late:
○ Exercises to improve your landing ability (like hopping and landing practice)
○ Exercises to improve your ability to change direction.
○ Practising unexpected change of direction or agility (like sport-related drills with a
ball, other unexpected challenges).
○ Gradually returning to sport-related activities.

You need to work hard during each phase in order to optimise outcomes. People with better
functional performance have lower chance of re-injury and better long term outcomes, including
lower rates of osteoarthritis (13, 14, 15, 16).

When to return to play

During the final stage of rehab, people often face a difficult decision - when are you ready to
return to sport? Some sobering news is that 56% of people do not return to competitive sport
after an ACL injury (17). Additionally, evidence suggests up to 24% of people can re-injure their
knee after returning to sport, however this risk is significantly reduced in people who pass
important return to sport criteria (18). You can optimise your chances of returning to sport and
reduce your risk of re-injury by considering the following:

Gleadhill CP, Barton CJ. Br J Sports Med 2021;0:1–2. doi: 10.1136/bjsports-2020-102273

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

1. Work hard on your rehabilitation, and if possible, work with a qualified professional to
provide you with the most up-to-date guidance.
2. You should wait at least 9 months before returning to sport if you have had ACL
reconstruction surgery (2). The longer your wait, the lower your chances are of re-injury.
If you have not had a surgical reconstruction, the optimal timeframe to return to play is
not clear, but you may be able to return to sport sooner.
3. Before returning to sport, you should include sport-specific training as part of your
rehabilitation, and you should pass a battery of performance tests (e.g. hop tests) (1, 12,
18).
4. Ensure you are confident to return to sport before actually returning (1). Time and quality
rehabilitation can help with confidence. In some circumstances, consulting with a sports
psychologist might be beneficial.

How to reduce the likelihood of injury

Exercise based injury reduction programs can reduce the incidence of ACL injuries (19). These
programs are important to undertake, whether you have had an ACL injury or not. Completing
these programs is an important consideration as you near the final stages of your ACL journey
and should be front and centre of your mind long after you return to sport. There are many injury
reduction programs to choose from, including the FIFA 11+ program, the Netball KNEE
Program, the Prevent injury and Enhance Performance (PEP) Program, the ACTIVATE World
Rugby program, and it can be a confusing time choosing the best option for you and your sport.
There are a few key components of effective programs, including regular strengthening and
neuromuscular challenges like landing and agility practice (19). Remember to involve your
coach and teammates when you are performing these programs - it’s everybody’s business to
reduce the risk of injuries.

Authors:
Connor P Gleadhill
Christian J Barton

REFERENCES
1. Ardern CL, Kvist J, Webster K. Psychological aspects of anterior cruciate ligament
injuries. Operative Tech in Sports Med 2016;24:77-83.
https://doi.org/10.1053/j.otsm.2015.09.006.
2. Filbay SJ, Grindem H. Evidence-based recommendations for the management of
anterior cruciate ligament (ACL) rupture. Best Practice & Research Clin Rheum
2019;33:33-47. https://dx.doi.org/10.1016%2Fj.berh.2019.01.018.
3. Diermeier T, Rothrauff B, Engebretsen L et al. Treatment after Anterior Cruciate
Ligament Injury: Panther Symposium ACL Treatement Consensus Group. The Orthop J
Sports Med published online first June 24, 2020.
https://doi.org/10.1177%2F2325967120931097.
4. Grindem H, Eitzen I, Engebretsen L. Nonsurgical or surgical treatment of ACL injuries:
knee function, sports participation, and knee reinjury: The Delaware-Oslo Cohort Study.
J Bone Joint Surg Am 2014;96(15):1233-1241. https://doi.org/10.2106/jbjs.m.01054.

Gleadhill CP, Barton CJ. Br J Sports Med 2021;0:1–2. doi: 10.1136/bjsports-2020-102273

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

5. Webster K, Feller J. Exploring the high reinjury rate in younger patients undergoing
Anterior Cruciate Ligament reconstruction. Am J Sports Med 2016;44(11):2827-2832.
https://doi.org/10.1177/0363546516651845.
6. Claes S, Hermie L, Verdonk R et al. Is osteoarthritis an inevitable consequence of
anterior cruciate ligament reconstruction? A meta-analysis. Knee Surg Sports Traumatol
Arthrosc 2013;21(9):1967-1976. https://doi.org/10.1007/s00167-012-2251-8.
7. Van Yperen D, Reijman M, van Es E et al. Twenty-year follow-up study comparing
operative versus nonoperative treatment of anterior cruciate ligament ruptures in high-
level athletes. Am J Sports Med 2018;46(5):1129-1136.
https://doi.org/10.1177/0363546517751683.
8. Diermeier T, Rothrauff B, Engebretsen L et al. Treatment after anterior cruciate ligament
injury: Panther Sympsosium ACL Treatment Consensus Group. Orthop J Sports Med
published online first June 24 2020;https://doi.org/10.1177%2F2325967120931097.
9. Frobell RB, Roos HP, Roos EM et al. Treatment for acute anterior cruciate ligament tear:
five year outcome of randomised trial. BMJ 2013;346:f232
https://doi.org/10.1136/bmj.f232.
10. Chalmers PN, Mall NA, Moric M et al. Does ACL reconstruction alter natural history; A
systematic literature review of long-term outcomes. J Bone Joint Surg Am
2014;96A(4):292-300. https://doi.org/10.2106/jbjs.l.01713.
11. Weiler R, Monte-Colombo M, Mitchell A et al. Non-operative management of a complete
anterior cruciate ligament injury in an English Premier League football player with return
to play in less than 8 weeks: applying common sense in the absence of evidence. BMJ
Case Rep 2015 Apr 26. https://doi.org/10.1136/bcr-2014-208012.
12. Van Melick N, van Cingel REH, Broojimans F et al. Evidence-based clinical practice
update: practice guidelines for anterior cruciate ligament rehabilitation based on a
systematic review and multidisciplinary consensus. Br J Sports Med 2016;50:1506-15.
http://dx.doi.org/10.1136/bjsports-2015-095898.
13. Pinczewski LA, Lyman J, Salmon, LJ. A 10-year comparison of anterior cruciate
ligament reconstructions with hamstring tendon and patellar tendon autograft: A
controlled, prospective trial. Am J Sports Med 2007;35(4):564-574.
https://doi.org/10.1177/0363546506296042.
14. Grindem H, Risberg MA, Eitzen I. Two factors that may underpin outstanding outcomes
after ACL rehabilitation. Br J Sports Med Published Online First: 14 July 2015.
http://dx.doi.org/10.1136/bjsports-2015-095194.
15. Toole AR, Ithurburn MP, Rauh MJ et al. Young athletes cleared for sports participation
after anterior cruciate ligament reconstruction: How many actually meet recommended
return-to-sport criterion cutoffs? J Orthop Sports Phys Ther 2017;47(11):825-833.
https://doi.org/10.2519/jospt.2017.7227.
16. Patterson B, Culvenor A, Barton C et al. Poor functional performance 1 year after ACL
reconstruction increases the risk of early osteoarthritis progression. Br J Sports Med
2020;54:546-553. http://dx.doi.org/10.1136/bjsports-2019-101503.
17. Ardern CA, Webster KE, Taylor NF et al. Return to sport following anterior cruciate
ligament reconstruction surgery: a systematic review and meta-analysis of the state of
play. Br J Sports Med 2011; 45: 596-606. http://dx.doi.org/10.1136/bjsm.2010.076364.

Gleadhill CP, Barton CJ. Br J Sports Med 2021;0:1–2. doi: 10.1136/bjsports-2020-102273

 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance
Supplemental material placed on this supplemental material which has been supplied by the author(s) Br J Sports Med

18. Grindem H, Snyder-Mackler L, Moksnes H et al. Simple decision rules can reduce
reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J
Sports Med 2016;50:804-808. http://dx.doi.org/10.1136/bjsports-2016-096031.
19. Arundale AJH, Bizzini M, Giordano A et al. Exercise-based knee and anterior cruciate
ligament injury prevention clinical practice guidelines linked to the international
classification of functioning, disability and health from the Academy of Orthopaedic
Physical Therapy and the American Academy of Sports Physical Therapy. J Orthop
Sports Phys Ther 2018;48:A1-A42. https://doi.org/10.2519/jospt.2018.0303.

Gleadhill CP, Barton CJ. Br J Sports Med 2021;0:1–2. doi: 10.1136/bjsports-2020-102273