One of the biggest questions we tackle on a daily basis is the "when should I return to my sport after ACL surgery?" question. This article will help unpack our approach, the research and the rationale behind our recommendations.
DATA DOESN'T LIE
Let's set the stage for the ACL return to sport crisis.
25-31% of ACL patients re-tear their ACL.
You have a 7x increased risk of re-tearing your ACL when returning before 9 months.
For every month you return before the 9 month mark increases your risk of re-tear by 10%.
The re-injury rate decreases by 51% per month up until the 9 month mark where it plateaus.
WHY?
There is a number of reasons why this could be the case.
Firstly, the surgery took a tendon (connects muscle and bone) and put it where a ligament (connects two bones) should be. These are inherently unique structures that serve completely different functions. The body goes through a process called religamentization, that essentially converts the tendon into a functioning ligament on the structural level. This amazing process takes 9-12 months to switch structures/function. It would makes sense that we would want the religamentization process to be close to done in order to have the strongest graft/ligament.
Secondly, it takes thousands of reps to truly rewire new movement patterns. After an ACL surgery rewiring the brain is crucial and this just simply takes time, repetitions, and consistency. 9 months allows us to appropriately and completely rewire the brain and address deficits without leaving any stones unturned.
Lastly, poor rehab often slows down the rehab process leading to longer time frames to meet return to sport goals. We often see plenty of unaddressed deficits such as large asymmetries in strength, stability, horizontal/vertical power and increased compensations even 9+ months after surgery with athletes we inherit from other clinics.
RETURN TO SPORT CRITERIA
There is no scientific consensus on return to sport criteria post ACLR, however, this would be our preference for bare minimum criteria needed to be considered ready for return to sport.
Hop test: >95-100% symmetry
SL vertical jump: >95-100% symmetry
Quad strength: >95-100% symmetry
ACL-RSI: >90%
These are all easily accessible, cheap testing measures that should be the baseline standard of care for ACLR patients.
EXCEPTIONS
Are there exceptions to the 9 month minimum rule? Ideally no. Based off the stats at the beginning we sleep a lot better at night knowing we at least hit the 9 month minimum with our ACLR patients.
However, there are times where an early return to sport may be warranted. Situations where scholarships may be off the table unless they are playing or one last game with their team we are open to that discussion. We make sure to discuss the risks of returning too early and make sure the patient is on board. We also ensure that our return to sport criteria doesn't change. No matter the situation we will not clear an athlete any earlier unless they pass all return to sport criteria with flying colors.
Our recommendation is always 9 months at a minimum and the closer to 12 months the better. This is not to keep patients in rehab longer than needed, but to ensure we leave no stone unturned in the ACLR process. We are incredibly passionate about ensuring this is a one and done event and if that means waiting 2-4 months longer till you are ready than so be it.
Hope that helps! Reach out with any questions!
We are a sports medicine physical therapy clinic located near North Canton/Akron, OH.