With names like Tom Brady, Joe Burrow, and Rob Gronkowski, ACL injuries have had their fair share of the spotlight from national sports media coverage over the past decade, and this NFL trio is not alone. ACL injuries are among the most common sports related injuries across both professional and youth sports alike, particularly in sports such as football and soccer. Often these injuries require surgical intervention followed by extensive physical therapy in order to return to sport. During this rehabilitation process, the two most frequent questions from my patients is (1) “When can I go back to playing?” and (2) “Can this happen again?”.
Contrary to what Grey’s Anatomy or Chicago Med may have you believe, medicine is rarely as black and white as we wish it was, and decisions regarding return to athletics and fitness activities are complex, multifaceted, and most importantly, individualized. There are protocols that we follow and a multitude of assessments that we, as physical therapists use to help continually assess and address the athletes’ individual needs throughout the rehabilitation process to best prepare him or her for successful return to sport. However, despite these best efforts, reinjury rates are high with recent research suggesting rates of a second ACL injury as high as 23% for athletes younger than 25 who return to sport1. This is a staggering and concerning statistic that begs the question: what can we do to prevent this from happening?
A recent article published in The Journal of Orthopedic & Sports Physical Therapy found that athletes who returned to “knee-strenuous” sports before 9 months after reconstruction had a re-injury rate approximately seven times higher than those who delayed return at or later than nine months. This means that delaying return to sport until at least 9 months significantly reduces an athletes ACL re-injury rate by seven-fold2. For the eager high school athlete motivated to rehabilitate quickly in order to return for the next sport season, this timeline can be a hard pill to swallow, however an important one. Missing one year of your sport to recover from an injury stinks but missing two years of your sport because of a reinjury really stinks. When it comes to return-to-sport, the one thing we cannot rush is time. The body takes time to heal, it takes time to progressively build back strength, speed, and power, and time is something that we cannot accelerate.
So, in answer to the two questions I opened this post with, I offer the same answer for both, and it is every physical therapist's favorite answer “it depends”. While a frustrating answer, it is the truth. The ACL reconstruction rehabilitation process is exactly that, a process, and a long one at that. Based on the current research, clearing a patient to return to sport before 9 months is too soon and waiting the extra time is worth the wait for a better chance of a successful return with decreased rates of reinjury. To that end, 9 months is not a magic number either, the decision to return to sport is a team effort between surgeon, therapist, and patient and based on multiple considerations to ensure the patient is physically prepared for the demands of their sport. No two athletes are the same, no two therapists are the same, and thus no two recoveries are the same. If you are an athlete beginning their ACL rehab journey, the advice I give you is this: prepare for a long ride filled with ups and downs, establish a positive relationship with your physical therapist early on- because you are in this process together, stay positive, and keep moving forward one day at a time.
1 Beischer, S., Gustavsson, L., Senorski, E. H., Karlsson, J., Thomeé, C., Samuelsson, K., & Thomeé, R. (2020). Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. Journal of Orthopaedic & Sports Physical Therapy, 50(2), 83–90. https://doi.org/10.2519/jospt.2020.9071
2 Wiggins, A. J., Grandhi, R. K., Schneider, D. K., Stanfield, D., Webster, K. E., & Myer, G. D. (2016). Risk of Secondary Injury in Younger Athletes After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine, 44(7), 1861–1876. https://doi.org/10.1177/0363546515621554
3 Ghaly, A. (2021, March 18). The Complete Guide to ACL Tear Rehab. Kinetic Labs. https://kineticlabs.ca/blog/the-complete-guide-to-acl-tear-rehab/.