ACL Recovery and Return to Sport

If you are 4-6 months post ACL surgery and your doctor tells you it’s okay to return to play ask him/her this: “how do you know I am ready?”

ACL is a devastating injury.

According to Dr. Tim Hewett, 85% of the doctors making this call are using no clinical data to make the decision. That is, they are looking at the calendar, listening to you say, please, please, please, and saying, “Okay, everything feels fine to me. Go ahead.”

It’s not a good idea. Here’s what I learned:

  • The incidence of re-tear is nearly 30%
  • Re-tear is especially high in females, aged 12-18, returning to “high activity” sports (involve high intensity jumping, cutting, stop-starting)
  • Females are at 5x greater risk of re-tear
  • Females are at 6x greater risk of tearing the ACL in the other knee
  • Not until 2 years post surgery is the knee fully recovered and normal proprioception returned

**New for me**: the ACL is not just a ligament; it’s a proprioceptor. A sense organ that gives your body information about it’s position. When it is replaced with a graft – usually hamstring or patellar tendon – the new ligament doesn’t have innervation. It doesn’t give accurate position-sensory information. It takes 2 years for this sensation to return, either from the new ACL or due to the supporting joint structures picking up the slack.

Ask kids who have new ACLs (or in my case a newly attached hamstring) how it feels when they return and they’ll tell you:

  • “It doesn’t feel right.”
  • “I’m off balance.”
  • “My step is catching or a split second behind.”
  • “The repaired side is strong but there’s a hitch in my motion.”
  • “I’m just not confident my knee will cut when I do.”

Two years out, the knee doesn’t raise the same questions for them. We’ve got to get them safely to 2 years. How? Here are your choices:

  1. don’t return to play
  2. return to a lower intensity sport or
  3. commit to an intensive neuro-muscular training program

We know these athletes. They are not the type to toss in the towel or learn to play chess. But gradual return to play takes patience and hard work. Not just stretching and strengthening but quickness and agility training that challenges motor coordination. They have to re-ignite the neuromuscular pathways designed by mother nature to protect their knees in the first place.

Even if your coach is not doing quickness and agility training (ugh!) do it yourself. Put paired cones in row (like train tracks) and make up the drills. Move quickly and accurately. Left and right, forward and backward, sideways with alternating lead foot. Find your rhythm. Do it over and over and over. Until it feels the same on both sides. Like it used to.

With thanks to Timothy Hewett, PhD and Christopher Kaeding, MD, from The Ohio State University.

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