By Frank Alexander
Baseball Health Network
INJURY PATHOLOGY
A soccer player makes a great run, has one defender to beat – plants their foot, twists the knee, and feels a pop. The player immediately goes to the ground clutching their knee in pain. A lacrosse defenseman checks the ball out of an offensive players stick, goes for the ground ball – tries to avoid an opponent – plants their foot, twists, and feels a pop. Similarly to the soccer player, they immediately grab their knee wondering what happened.
The athletic training staff rushes to the player, assesses the injured knee, and the player doesn’t return to competition. In the doctor’s office, the knee has great laxity and a tear of the anterior cruciate ligament (ACL) is confirmed. Unfortunately, the only way the ACL will heal is with surgery. It will not heal on its own. There is significant swelling and a decrease in range of motion (ROM). Before a surgery day can be set, the swelling needs to be decreased, range of motion must be improved, and while strength will not be 100% pre-surgery – it needs to be improved as well. To achieve these goals, prehab is recommended. Prehab is pre-surgery rehab specifically designed by an athletic trainer or physical therapist targeting ROM, quadriceps strength, and swelling.
COMPONENTS OF PREHAB
There are three main goals of prehab: decrease swelling, increase range of motion, and increase strength. After an injury, the body has a natural reaction to protect itself and a consequence is swelling. Swelling in the knee will restrict range 
of motion and needs to be decreased. If swelling is not diminished before surgery, the outcome will not be favorable for the patient. By doing prehab exercises, icing, and taking anti-inflammatory medications, swelling can be decreased. Many athletes have heard of the GameReady unit. This unit combines both ice and compression through a sleeve that surrounds the knee. Another unit similar to the GameReady is the CryoCuff which operates in a similar manner. These units are highly recommended in both the prehab and rehab phases. They can be discussed with our staff in the office.
The knee is a joint that, when healthy, has 0 to 130 degrees of motion, or more. When the knee is fully extended, we say it is at 0 degrees. In a healthy knee, it can flex (bend) to 130 degrees or beyond. Not everyone is the same and range of motion varies from person to person. However, it is said that the knee can be functional at 125 degrees of flexion and that is the goal before surgery. Exercises such as wall-slides and assisted flexion are parts of a good home prehab exercise program. While flexion is important, extension should be emphasized. Extension should be emphasized because if it is lost, extension is difficult to get back. Physical therapists will be able to flex the knee post-operatively, but extension has to be a focus of the therapist and patient as well. Ways to prevent a loss of extension is by performing exercises such as quad sets and straight leg raises. Another good way to aid extension is, while watching TV, icing, or hanging out, prop a few pillows under the ankle and keep the toes towards the ceiling. This will allow gravity to gently pull the knee into extension.
In addition to decreasing swelling and regaining range of motion, quad strength is another key component of prehab. Quad strength will help avoid atrophy – which is a decrease in muscle mass. Exercises such as quad sets and straight leg raises will help with quad strength and control. These two exercises are not only a large part of prehab, but also of the immediate rehab phase.
READY FOR SURGERY
Once improvements are made, the patient is ready for surgery. The prehab process varies for each patient with the ideal time from injury to surgery being 2 weeks. Timelines are not set in stone so while some patients are in the average, some may be quicker and others may be longer. Another factor is severity of injury. Many ACL tears happen in addition to other injuries within the knee such as medial collateral ligament (MCL) tears and meniscus tears. These other injuries need to be taken into account for timing of surgery as well. The more effort put into prehab, the quicker surgery can be scheduled. For many athletes, timing is of the essence and getting ready for the upcoming season will take a lot of work. The hard work doesn’t stop on the day of surgery, athletes will need to keep their work ethic for the months following surgery to ensure staying healthy once they return to the athletic fields.
When an ACL tear is diagnosed, Dr. Ahmad’s office will provide each patient with home exercises that should be done in addition to any prehab. In some cases, prehab may not be necessary but this is not always the case. We suggest that each patient does not compare their injury to another’s. Everyone heals differently but if maximum effort is given throughout the process, a return to the field is well within sight.
Frank J. Alexander, Jr., M.S., ATC, is a Physician Extender to Dr. Christopher Ahmad, Department of Orthopaedic Surgery at Columbia University Medical Center.