| By: Julie Eibensteiner PT, DPT, CSCS Get through these 3 key stages and your chances of another injury go down significantly. ——————————- We often tell our ACL athletes that they are entering a “don’t be an idiot stage.” We joke that we may need to make them a t-shirt as a reminder to be careful of 3 key stages where they can have a false sense of security. To be clear, we aren’t advocating for paralyzing fear – that brings up a whole different sets of challengers for the patient (and parents a lot of time as well!) but, we are advocating for the middle ground. We often say that the two most dangerous drivers on the road are: 1. The one paralyzed by fear. 2. The one who is overconfident. The best drivers typically have a healthy respect for the dangers of driving and all that go with it – same goes with ACL rehab. ——————————- With that being said, if you or someone you know is going through ACL rehab and chomping at the bit to get back to sport – please be careful of these 3 opportunities for idiocracy. 1. The 2nd 4 weeks (weeks 4-8) phase As you start feeling better functionally, the ACL graft is typically getting to it’s weakest. Yep. Read that again. When they reconstruct an ACL they harvest it from other places (usually patellar tendon, quad tendon, or hamstring). The new “ligament” loses strength for 4-8 weeks as it gets used to it’s new home and gains a good blood supply. In the meantime, the first 4 weeks of rehab is typically about getting swelling & pain down, quad function and range of motion back, and returning back to walking and moving better. It’s easy to take things slow, but be careful of those next several weeks where you feel good but the graft isn’t (and be careful of others around you who have no idea.) 2. The “I can run and move” so “I can play” phase (4-8months) The majority of new research on ACLs is pointing to an ACL injury being a brain injury as much as it is a knee injury. The majority of injuries are happening without direct contact to the knee. The theory is that it is a processing & communication error between the brain and limb. Many athletes feel “athletic” again when they can run (usually in the 12-20 week time frame, depending on when they meet the bar on a series of competencies). Beware – there is a stark difference between the demands of running in a predictable fashion and returning to the messiness of sport. Just as the muscles and ligaments need time to gain strength, the brain needs time and prolonged exposure to building up capacity and proficiency to process, react, and move well in a chaotic environment again (and hopefully better this time!) This is done in series of long-drawn out return to training phases. MOST PEOPLE RUSH THROUGH THIS STEP – which is why we believe #3 is an issue. Studies show there are so many repeat injuries happening quickly after returning to sport. ****The most important muscle to strengthen in this phase is the PATIENCE muscle. Competencies drive this phase, not pure time. Trust the process. 3. The double shark bite phase (3-6months post return to sport and up to 2 years.) The peak incidence of ACL injuries is typically around 16 years old with females being a little earlier and males a little later. We say younger athletes are heading toward shark infested waters before this time. Knowing the risks and being prepared via building up physical competencies is wise. Numerous studies repeatedly show that athletes under 25 returning to cutting or pivoting sport have an ACL re-injury rate of 25-40% with athletes under the age of 14 having a reinjury risk up to 50%. The greater majority of these injuries happen within 2 years with the peak time-frame of a 2nd injury (either to the same or opposite leg) in the immediate 3-6 months after returning to sport. Time is key. Preparation and competency is key. Patience is key. Athletes going back to competitive sport need to continue to swim away from the sharks. Get to that 2 year mark. |
 Image: ACL Graft Healing at Time 0, 3, 6, 12 months post ACL reconstruction with patellar tendon graft. Notice the lighter color on the 3 and 6 month images which represents less overall healing maturity of graft. Credit: Freddie Fu MD (University of Pittsburgh) DID YOU KNOW? The ACL graft at 6 months is 50% of normal breaking strength, at 8 months 80% of normal breaking strength. Shelbourne, K. D., & Nitz, P. (1990). AJSM Simple decision rules based on functional testing can reduce the risk of re-injury by 51% after ACL reconstruction when followed properly and when return to sport is delayed until at least 9 months. Grindem, H., et al (2016). BJSM Athletes who return to sport before 9 months are 2.5 times more likely to experience a re-injury compared to those who wait until after 9 months. Ardern, C., et al (2014). BJSM. ——————————- Quick Recap 1. The new ACL is typically weakest at 4-8 weeks from surgery, not the day after surgery. 2. Being a functional human is not the same as being a game-ready competitive athlete when it comes to knee ligaments (and the brain of the athletes they are connected to!) A poor rehab is done quickly, a great rehab lasts the test of time. 3. It takes 2 years to swim out of the shark invested waters after being bitten once. Your long-term habits of taking care of your body – warm up + strength training + quality sleep and nutrition, all done with intention – are you biggest insurance policies after a patient, high quality rehab. |
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