The period between the end of physical therapy and the start of sports-specific conditioning is a critical time for young athletes following an an anterior cruciate ligament (ACL) tear or rupture, reconstructive surgery, and months of rehabilitation. While an athlete is likely to be very eager to return to play, he is also probably afraid of another injury. Such a response is normal, but can be lessened through a proper progression and support from parents and coaches.
There are three important things parents and coaches can do to help young athletes return to play in a safe, efficient, and productive manner:
#1: Identify probable cause of injury
Understanding how and why the ACL injury happened is critical, especially if, like two-thirds of all such injuries, it was not the result of player-on-player contact (e.g. non-contact ACL injury).
Some non-contact ACL injuries can result from wearing the wrong kind of footwear that provides either too much or too little traction, or from an uneven playing surface, which can result in excessive loading of ligaments and muscles and may contribute to improper landing after jumping. In such instances, the risk of future injury can be minimized with proper footwear and through appropriate monitoring field conditions for holes or other irregularities.1
Most non-contact ACL injuries, however, result from biomechanical weaknesses or imbalances that caused the ACL to tear or rupture under the stress, most commonly stemming from:
- an anatomical imbalance or weakness (e.g.. females are believed to be at increased risk of ACL because they have wider hips than males)
- poor balance
- poor joint control (proprioception)
- weak hip musculature
- weak core musculature
- bad foot mechanics
- overtraining /undertraining; or
If an athlete has always had poor balance and has difficulty standing on one leg, it could result in a future injury. If the athlete's knee had been hurting for weeks, identifying the reason for the pain (remember: pain is the body's way of saying something is wrong) is important to correcting the problem and minimizing the risk of future injury. Weak hip and core muscles put the entire body at risk of injury, compromising more than just the knee. Identifying a probable cause is important to motivate change. This step will offer more clarity and focus for future re-conditioning and injury prevention maintenance.
#2: Address Entire Body Preparation - Not Just the Knee
While an athlete is sidelined , the entire body gets out of shape. The cardiovascular system cannot operate at full capacity without the legs to push the limits (added note - swimming will get the job done when allowed by the physician). Muscles, ligaments, tendons, and bones throughout the body., which had become accustomed to working in a high stress environment for competition, have lost their strength. Innate athletic abilities, such as the neuromuscular system's ability to detect small internal and external changes in environment, are lessened, simply because they have not been stimulated for months.
All athletes coming back from an ACL reconstruction therefore need to make sure to address, first and foremost, the following:
- joint stability and mobility
- core strength
- body mechanics
Then, and only then, can an athlete begin training regimens designed to improve:
- speed; and
A failure to address joint stability and mobility, flexibility, core strength, balance and proper mechanics will significantly increase risk of future injury, especially as a deficiency in one of these five areas may have been the main cause of the ACL injury in the first place.
A good sports rehabilitation specialist will suggest exercises and sports-specific regimens to return to play. Check with your child's physician and physical therapist to ensure they are appropriate. Remember also that, if they are doing their job, their support should be ongoing and not end when the athlete is discharged from their care. Hopefully, they want to make sure an athlete never comes back, except, perhaps, to say how great they are doing!
#3: Progress, Re-Assess, Continue
Each athlete will progress through their recovery at the pace that is right for them, not simply what a manual or guideline suggests. Some athletes are able to return a couple months earlier; in other cases, a few months later. The length of recovery depends on many factors, including the individual, the extent of damage, the recommendations of physician, and the sport to which the athlete is returning. The important concepts to consider are:
- Progress appropriately. Push, don't press. Saying "the sheet says you should be doing (XXX) by now" does not help. Encouraging an athlete to keep working towards their athletic goals is more important than a generic timeline.
- Re-assess every few weeks to establish progress. The process of recovering from an ACL injury is very long and having objective measurements to show that an athlete is getting better helps tremendously. It boosts the self-esteem and helps an athlete begin dreaming about the day she gets back on the court to drain a three-pointer at the buzzer beater, a dream that she may have not had the first couple of months post-injury because of the pain and physical limitations resulting from her injury. The sheet may say "progress to running at week 14" but if the athlete cannot balance on one leg, don't continue on. Furthermore, an athlete who is way ahead of schedule should talk with their doctor before progressing. Healing occurs at a pretty predictable rate and pushing faster than the maturing ACL is a bad idea.
- To return to sports competition, the knee and body must continue to progress. This means pushing appropriately and regularly as recommended by the physician. The ACL must first heal, but then it needs retraining and conditioning. This will only come from continuing to push gently against the knee's limits (again, safely and as indicated by the surgeon) to return to play. The trauma from surgery and deconditioning from inactivity requires considerable effort and commitment to return to competition. Mentally, an athlete needs to see the "light at the end of the tunnel" to get through months of reconditioning.
Keith Cronin is a physical therapist in the St. Louis area and a MomsTeam expert.
Koutures C, Gregory A & The Council on Sports Medicine and Fitness. Injuries in Youth Soccer. Pediatrics 2010;125;410-414