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Setting Realistic Expectations for the ACL Athlete

I remember when I tore my ACL for the first time. I was sixteen years old, and I had just committed to play NCAA Division I soccer at Penn State. Just like any athlete with lofty aspirations for herself, I was devastated by the idea of sitting on the sidelines for a prolonged period of time. Prior to this injury, I never had to. I had rolled my ankles a handful of times but never had to sit out for more than a day or two — Nothing a little bit of Advil or athletic tape couldn’t fix.

I quickly learned that this injury was different, and it rocked my world. Reflecting back, I recall one instance where I was feverishly writing down a timeline for myself in my training journal. I had spoken with a well-intentioned coach of mine who had tried to offer consolation and motivation by stating that she had successfully gotten back to soccer four and a half months after her ACL reconstruction in the 90’s. She said that with the right mindset, anything was possible. 

At the time, I believed this. I was going to get back to sport in 4.5 months and be a better, stronger athlete than ever before.  I had grieved my injury. I had gotten over it. And I was about to hit the gym every single day for what would turn into the next 516 days. 

I’ll fill you in on a little secret. I didn’t get back to sport in four and a half months. My recovery was riddled with other complications, from muscle strains, to ligamentous sprains, to bone stress injuries and everything in between. It wasn’t until I got to Penn State two years later, that I was able to actually PLAY soccer. 

So why was my road to recovery so rocky? I had a maladaptive mindset when it came to my rehab. Don’t get me wrong. I had a fantastic physical therapist, who tried to set realistic expectations with me, but I was a 16-year-old spitfire who just wanted to prove the world wrong. Looking back, this has been one of the best lessons of my life and has greatly influenced the way I now practice physical therapy. Do your best until you know better. Then, do better. 

As a now performance physical therapist, I have done a ton of research in the domain of ACL rehabilitation and ‘prevention.’ I also have a ton of experience with ACL rehabilitation, as I have torn mine a number of times. Blending my own experiences with the latest research, I try to spare my patients the lessons that I had to learn the hard way. Here are a couple of tips for anyone going through, or treating, ACL injury:

1. Set Realistic Expectations on Day 1

One of my biggest obstacles during ACL #1 was that I had unrealistic expectations. Now, I agree that with the right mindset, almost anything is possible. But keep reading through point number two, as to why this isn’t necessarily true with ACL rehab. 

As a clinician, I don’t enjoy the first conversation I have with an injured, potential ACL client. I know that what I am about to tell them is scary, hard to stomach, and will often push them right out the door to a different provider who can guarantee that he/she will be back to sports in 6 months or less.

Here’s the reality. Retear rates are HIGH. Anywhere between 20-30% of all ACL-R athletes will sustain a subsequent ACL injury and accelerated timelines may be in part to blame. Multiple research studies have found that returning to a knee-strenuous sport BEFORE 9 months following ACL-R is associated with significant risk of sustaining a second ACL injury. Beischer et al. found that this risk was 7x as high for athletes returning back to sport before the 9-month mark. The Delaware-Oslo ACL Cohort Study also corroborated this finding, by stating that reinjury rate is significantly reduced by about 51 % for each month return to sport (RTS) is delayed until 9 months after surgery. Still, other researchers like Ardern et al. note that some patients will even take up to 2 years to return back to sport, due to demographic, physical function, and other psychological variables.

2. You Can’t Rush Physiologic Healing

Pavel Tsatsouline said it best when he wrote, “You can’t rush stable adaptations.” This is especially true when it comes to ACL rehab. Did you know that your ACL autograft is strongest on the day it is surgically implanted, and that over the course of the first 8-12 weeks it actually weakens in strength. It actually reaches its weakest point at around the 3-month mark. This initial period of healing is filled with graft necrosis and hypocellularity resulting in a decreased capacity to handle load. Allografts (or cadaver grafts) take even longer to reach this point! This is where it can get tricky for clinicians, as patients generally start to feel really good by this point in time. Their muscles (and psyche) may want to do more running, jumping, and cutting, but their grafts are not ready to accommodate these demands. While such activities are certainly okay to initiate prior to the 9-month mark, the process of re-vascularization and “ligamentization” takes anywhere from 9 to 12 months, with full graft maturity occurring around the 2-year mark. This is why some clinicians have postulated the idea of keeping patients out of sport for 2 years. Could you imagine?

Spoiler alert: I can and it’s not fun. During the course of recovery from my second ACL, I learned this lesson first-hand. My graft ruptured during a change-of-direction maneuver in rehab at the six-month mark, and I got the privilege to start all over with ACL reconstruction number three.

3. The Journey is Just as Important as the Destination

While it seems cliche to say, I would like to encourage all athletes going through an ACL rehab to view the process as an opportunity to get better. Find a provider you trust and come up with a game plan. Don’t be married to rigid deadlines, rather aim to tick the boxes on major recovery milestones when you are ready. I really enjoyed Buckthorpe et al.’s clinical commentary where the authors walk readers through a ten task-based progression for safe return to sport following ACL-R. Using their logic, you can systematically come up with achievable tasks based on yours or the patient’s strength/ability and time from surgery. This progression includes walking, bilateral squatting, single-leg squatting, bilateral landing, running on a treadmill, bilateral drop jumps, single-leg deceleration, single-leg drop jumps, 90-degree cutting, and finally sport-specific multi-directional movements. Remember to be gentle and patient with yourself, while celebrating your little victories. Trust me when I say that they will eventually turn into big victories.

In conclusion, always set realistic expectations straight out of the gates. This goes for patients or for providers, and can just be a great strategy for life. Be an informed consumer or practitioner. Look at the data in terms of ACL-R and safe return to sport. Come up with a rock-solid game plan, and be wary of any clinician who guarantees a quicker recovery than industry-norms without increased risk of reinjury. In the words of Tim DiFrancesco, “Bragging about your speedy return to sport after ACL surgery is like bragging about going 100MPH on a busy highway. Both can be done and both have a high likelihood of crash and burn.”