Clinician's Commentary on Nakamura et al.

Anterior cruciate ligament (ACL) injuries of the knee are a common occurrence in the sporting environment, resulting in significant loss of time to sport as the athlete goes through their individual recovery process.^2,3

This paper focuses on the surgical pathway and highlights the value of using a model or framework to consider numerous factors that may influence outcomes.¹

Application of models and frameworks can be of value and provide structure when considering resource allocation, patient recovery, and clinical outcomes.^4,5 A contemporary approach to postoperative care for patients that have undergone anterior cruciate reconstruction (ACLR) surgery would incorprate a patient centred model with shared decision making.⁴

There is a significant body of work published on ACLR surgical outcomes and the associated revision rates after primary ACLR.⁶ It is currently accepted that optimized outcomes are the result of shared decision making with the athlete, and optimal surgical technique partnered with appropriate, comprehensive, evidence informed pre and postoperative physiotherapy throughout all phases of rehabilitation and the return to sport (RTS) process.^3,4,6,7

Adherence to clinical best practice is thought to help minimize secondary damage to structures and biologic processes within the knee to help reduce the future impact of post-traumatic osteoarthritis (PTOA) that is reported to occur in up to 50%–90% of patients after ACL injury.^8,9

The authors of this paper highlight the variety and complexity of factors that may contribute to each individual circumstance as it relates to optimizing the postoperative rehabilitation experience.¹ Given the narrative this paper provides; it is easy to imagine a postoperative ACLR clinical vignette that would result in dramatically different rehabilitation experiences by changing a few variables related to social determinants of health discussed in the social ecological model.¹

Clinical Vignette

Consider a 17-year-old soccer player with hopes to play in the women's World Cup one day. She is 4 days post ACLR and ready to begin her year long rehabilitation process on her journey to return to sport. The physiotherapy clinic is a 10-minute drive away from her home. This is not an issue as her twin sister has a car and can drive her to the clinic directly after school each day as both of her parents have to work.

Now consider the same situation where there is no car and the athlete needs to get home immediately after school to look after a younger sibling.

Finding the “correct fit” for postoperative ACLR rehabilitation can be confusing when taking into consideration clinical best practice and personal circumstance. By establishing an authentic therapeutic alliance, physiotherapists are well positioned to play a key role in helping navigate and customize the postoperative rehabilitation experience. Being empathetic, valuing and incorporating patient goals and needs are essential for success in this process.¹⁰

This paper has provided an opportunity to discuss and reflect on the following (1) the utility of models and frameworks in the rehabilitation process, (2) the complexities and variety of factors involved with each patient's unique circumstance in postoperative ACLR rehabilitation, and (3) the opportunity for physiotherapists to be partners in helping guide the process. Caution should be exercised in making any direct extrapolations from the results of a small sample size of ACLR postoperative patients in this paper.