After a Knee Injury, Be Wary When Returning to Sports

Reading through this article and comments is a reminder of an entire industry that has lost it way. I am a 60 year old male that was walking to a gym in Pittsburgh and was hit by a car. My planned workout for the day was several sets of 400 pound squats. Instead I woke up in back of an ambulance with a concussion two small knee fractures and a fully torn MCL on the femoral side. That was three months ago - yesterday I was again doing sets of squats with 400 pounds. What was my PT you ask? I allowed the tendons to sufficiently heal and then resumed barbell training - progressively increasing the poundage. I am proof that the simplicity of barbell training done correctly with progressively heavier weights can not only keep you alive when catastrophe strikes but also is the antidote to regaining complete functionality in your chosen sport - all without “doing PT”

I was a Judo player through my twenties and early thirties until a poor O Soto Gari snapped my right ACL like an over-wound guitar string. (I still finished class that day) It was repaired with a patella tendon graft by a locally famous surgeon. A couple years later I was playing soccer on some terrible artificial surface, my unbalanced, 40 pounds overweight bod put too much lateral pressure on my left knee, resulting in a torn ACL and shredded meniscus. The cartilage tear is actually worse than the ligament part because its chronic and painful. I haven't played tennis, soccer, or Judo since. Now I'm in my forties, fatter than ever, and introducing my five year old son to the mystical world of Kuzushi and Kake. I long to be out on the mat with him like nothing else I've desired in recent memory. My body tells me no, but my health insurance is good, and my denial is impervious to your rational arguments.

I tore my ACL in 1990 (I stepped off a ledge and fell) and had it repaired in 1997 at Kerlan Jobe in Los Angeles (where I lived at the time), the team doctors for the Los Angeles Kings, Lakers, etc. Magic Johnson used to work out at the same gym as me (Gold's) and I told him I was going in. "It's all in the rehab" he said. And yes, he was right. I was told it takes a year to properly recover from a torn ACL and that is what I experienced. I understand that if you are a multi-million-dollar professional athlete, there is intense pressure to come back sooner. But if you're not being paid millions to do sports, I think you are really being, frankly, stupid, to try and compete or participate in stressful sports, including skiing, less than a year after surgery. 22 years later both knees are perfect, and I lift weights and do cardio every day. I'll have my 60th birthday in a month.

After years of partial tears, which were never correctly treated, I finally did it: I ruptured my ACL, tore my meniscus, and more. Yes, I did it skiing. It's been 5 months now w/surgery next month. After my knee calmed down I started physical therapy. While PT is important, it lacks a significant aspect: treating the entire body. Once a body part is so acutely injured other body parts work to compensate for the injury. My other leg, quads, hamstrings, & glutes and even hips,took on the additional, and new, burden of compensating for my injured knee. PT- which typically treats almost exclusively the injured area, is inadequate. It doesn't consider the other parts that are affected which now function unevenly and improperly. Consequently, in addition to PT I now work with a personal trainer, one who knows and understands how the muscles work together to promote proper functioning. I have seen others take this approach with great success. With the trainer I am working on core and upper body as well (we do use our upper body to ski - like keeping our upper body straight down the fall line while our legs control and guide us down the hill). Do I want to ski, dance, and scuba dive again without or reduced risk of a repeated injury? Yes. Does this approach increase the investment in cost, time and effort? Yes. Every time I want to cancel a session, I visualize myself back on the slopes and dance floor. Good motivation.

Thanks for the warning. My patience for healing time is pretty well run out, and you just motivated me to go slow.

I have suffered a torn ACL. I am aware of the autograft and allograft repair strategies. Can anyone comment on emerging alternative strategies. Young, aggressive athlete, with lifetime of active, organized sports ahead. Full return to sport is the goal. Curious on any new wave surgical methodologies. Thanks.

I ofter our story of a complicated recovery to those who are struggling with recovery. Our daughter had one ACL tear that required multiple surgeries, 18 months of physical therapy, sports medicine counseling for guidance of all of us (including the surgeons) which led to a movement training program that focuses on the neuromuscular attributes of, well, movement. It took years for her to recover her skills because when your quads do not work all the other muscles in the injured leg atrophy. For those who may be wondering what in the world? Well, reflex sympathetic dystrophy is the answer. Happily she is recovered after years of hard work and now dances West Coast Swing to fulfill her lifelong need to move.

Do any of these "return to sports" tests even test the athlete in their respective sports? Do they get the volleyballer on the court and test actual volleyball movements? Most return to sports protocols are not sports specific. Exercises done in a controlled environment where outcomes are easily predictable (i.e. knowing exactly where to jump and land) have little carryover to game-time situations. Current return to sports protocols stop short of "sports specific" training. Box jumps, ladder drills, side-shuffles...are not sports specific. Playing a game of basketball is sports specific. Until this is standardized, risk of reinjury remains increased.

I tore my ACL, and took two years to get back to playing hockey at the same level. My surgically repaired leg is still not as strong as my other leg. I only play hockey and ski now - no more soccer or ground/turf games. The real problem was that a far away, unseen doctor at a for-profit insurance company read my case file and decided that I was healthy after the exact amount of hours of physical therapy covered by my insurance plan. After that I was on my own, and the muscles never got back to their original strength. After that my gait changed and after several years I had stressed my opposite hip. The solution was more physical therapy. But, of course, the doctor-prescribed physical therapy was denied by the insurance company. And we're afraid of the government running our health care?

There’s no big mystery here. If HOW the athletes moves (their movement pattern) is not evaluated and addressed during the rehab process-they are likely to reinjure. If they’ve been rehabbed but haven’t been trained in muscle activation patterning (which can take 30,000 some repetitions to establish a new pattern) to correct their movement, the job isnt finished yet to return them to play.

If you are not making $85,000,000 over 3 years it is not worth returning to the sport that ruined your knee. I found solace in cycling and skiing (with a marvelous brace when doing downhill). I miss running not at all, finding 60 mile rides even more satisfying.

The psychological aspect of returning to running has been the most difficult for me. The fear of re-injuring myself kept me away from my sport for what seems like a long time. It's been almost 5 months since my arthroscopic injury. I hobbled around for 8 months in pain before I finally had surgery. I never knew when I was going to feel the pain; it was so random. That fear stayed with me. I am running again and it's the constant positive self-talk that is giving me confidence. I am an older marathoner and am finally working through this, which frankly has been worse than the pain itself.

I'm glad to read that "confidence" is a factor. I thought it was just me. I'm a 64 y/o, former athlete who ran regularly until I fell off a ladder and ruptured my right ACL 2 years ago. I received a cadaver tendon to replace my ACL and all has gone well physically. Psychologically, it's another story. I'm terrified of slipping on wet surfaces, snow, ice, wet leaves, and re-injuring my knee. That lack of confidence has kept me from returning to my daily jogs. I'm sure I can do it physically, but I'm still trying to overcome the psychological hurdle. Compounding the issue if the fact that I've put on weight and now I'm concerned that my aerobic fitness has taken a hit. I can relate to how a lack of confidence can increase the likelihood of re-injury, just as much as overconfidence can. IMHO, psychological rehab is every bit as important as physical rehab when it comes to ACL injuries.

I had a motorcycle accident in early September. Fortunately, nothing was broken and a normal X-ray was negative. But.... I still have constant pain in my left knee. It just doesn’t seem to get better. Maybe it’s time for an MRI?

I have had ACL replacements on both knees. The right one when I was 20 (skiing). The left one when I was 28 (soccer). During the first snap, I was a varsity athlete (swimming) and wasn’t allowed to flip turn for nine months although I was back in the water. I had both physical and athletic therapy after both surgeries and felt ready to get back to action after the nine months. I’m many years older now and have done triathlons, play hockey and Ultimate, ski in Revelstoke (super steep) and dance the night away on my cadaver ACLs. I have never thought about avoiding “stressful exercise” or that my knees couldn’t take it. I’m Canadian though so maybe our health system allows for more time and money to be put into our kneeds.

The ACL is one major ligament in a structural chain of other ligaments and muscular support. As a Regenerative Medicine doctor, Osteopath and Musculoskeletal Sonographer, I evaluate hip tendons and ligaments, other accessory knee tendons and ligaments under ultrasound and treat these common weak spots with Regenerative injections. If a patient’s pelvis is hypermobile then their hip will rotate creating a leg length discrepancy. This is the set up for an ACL injury and it isn’t going to improve with strengthening quads or hamstrings. Core and glute strengthening are sometimes sufficient but in many cases the underlying issue is laxity of the pelvic ligaments and tendinosis of the Vastus Medialis and Gluteal tendons. Treating these areas with Regenerative injections allows the body to heal these areas that may never heal otherwise, then physical therapy works better when the structural alignment and injured tendons associated with the muscles that need to be trained have been healed. At the very least, this type of evaluation should be performed in addition to typical Physical Therapy assessments because many of these issues cannot be picked up without assessment under ultrasound. Often times dormant injuries and imbalances silently lay beneath the surface that cause other areas to be under more stress and eventually show up as the primary injury. In addition, for the ACL that never healed tight, Regenerative injections are a way to improve the fiber density and strength.

Not once in this article was a physical therapist mentioned in any capacity, a professional who is essential in the rehabilitation after an ACL. Injury. We (I am a physical therapist) are the ones who work with individuals after ACL repair, or when they’ve injured their ACL and want to avoid surgery, 2-3 times a week for months. A thorough conversation with a therapist could have given you great insight about what it takes to truly return to sport, and would have given your readers a much more informed and complete picture of this process. Hopefully next time someone writes an article about rehabilitation after an injury, you interview those who are closely involved with the process.

Once again this article uses a "relative" percentage to provide something extraordinary: a whopping 235% increase in the probability of injury. 235% of what? of 2%, of 5%, of 50%? Enough with the relative percentages in every study. Give me the real facts and I can compute the relative probabilities. 235% may be nearly no significant difference at all!

Two obvious thoughts: 1. These "repairs" just don't work well. Period. 2. Perhaps the other knee blows out because these athletes are simply prone to these injuries--both knees

Jumping off a one foot wall results in a landing force of four times body weight. Almost no one can create four times their body weight with the muscles of their legs. So how do our joints and muscles survive this common high level of peak force. We cannot create high force levels with muscular effort, but our muscles have a robust system of absorbing the shock of outside forces called eccentric contractions. Like a bungee cord absorbing the huge force of a falling body, muscles can lengthen and dampen the shock of outside forces applied against our joints. These forces are far above what the muscle can generate itself. Until we are able to train athletes with gradually increasing, supramaxaimal loads that forcibly lengthen the muscles around joints, we will make no impact on the re-injury rate of ACL tears.

There is one easy one to avoid this and much more. Don't participate in the types of sports that produce these injuries. You can do moderate exercises and avoid all of this. I was running into moderate problems with knees, feet yrs. ago despite the fact I was doing everything right re these exercises and my doctor told me to avoid more stressful exercise and take up less stressful exercises. I am 70 yrs old now and in excellent health and never had a back, knee or foot problem. I thank the doctor till this day until she moved out of town.

My daughter blew her knee out in a field hockey game when she was 16. She used her own patella tendon for her surgery, went through a grueling 10 1/2 month rehab, took a return to play test and failed by a few points in the other knee. The next month she passed and was back on the field. 4 years later no issue. I believe using one's own tissue makes a stronger ACL. Other kids who used cadavers blew their knees again at a surprising rate. Autografts vs allograft data should be included in the study. Also, many doctors feel the need to tell the athlete a number they want to hear vs the true timeline for return to play. It's about a year more or less IF you do the work.

First of all, the question is not about the reliability of the testing, but its validity. This is an article about sports science, so it ought to use the correct terms. Second, since when has it been generally decided that are ACL grafted knees ready to go in 6 months?

Most important, listen to your body. Do not ignore it!

Still skeptical on how reliable the return-to-sports testing is I personally would just wait it out even though my life revolves around exercising and sports rather than a form of assessment that may be counterproductive and exacerbate my original issue or start negatively affecting the healthy leg.

I broke my leg two years ago this Friday riding my bike when the front wheel slipped out from under me on a wet road. I felt my femur snap as the paramedics lifted me off the ground. This was due to a 5 x 5 cm bone tumor that was discovered two weeks before but my doctor permitted me to keep cycling until knee surgery a year away. Surgery and the tumor is under control but my leg is now bowed a few degrees off straight and I don’t like to walk like before. My gait has changed and I feel I may be in the early stages of destroying my hip. The trickle effect of injuries is something else.

As a mature (50+) athlete with really bad knees, I have a very unscientific idea why the returning athletes are 235% more likely to blow the other ACL. They are either consciously or unconsciously guarding the leg repaired by surgery. Both my knees are bad - multiple MCL and LCL damage over the years, tons of scar tissue, meniscus tears, and now, arthritis and bone-on-bone issues where there is no meniscus. My left leg has been damaged over the years more than my right. I find some days that I am unconsciously "gurading" my left leg and putting more weight on my right leg when doing some things. (E.g. Back Squats - at heavier weights, I sometimes realize part way through a set that I've subtly shifted my weight to my right leg - it's not enough of a shift for my coach or trainer to see, but I can feel it. ) I try to correct the shift but it happens. Our brains are programmed to protect our bodies in "combat" - therefore if something in the brain thinks that the "weaker" or rehabbed leg is at risk, the body is going to shift to protect. I don't know if it's something that can be studied, but my informal study of it in talking with other older athletes with chronic injuries - seems to hold true.

I got injured ACL while skiing. A well-known sport doctor checked and told me that I don't need a surgery but that I wouldn't be able to ski again. After the pain is gone, I started skiing again, and luckily I haven't experienced another ACL injury since then. Only the problem is that I tend to damage shoe heels more often than the other one.

I have a nephew-in-law, a college and NFL football player, who tore one ACL and then the other twice over a ~4 year period. He had the best rehab available but clearly it wasn’t enough. I wondered if there might also be structural factors that contribute to these injuries. Not touched upon here.