I’m sure Washington Redskins fans are shaking their heads wondering why Robert Griffin III isn’t playing like he was prior to his injury last season. Shouldn’t he be at the top of his game just like Adrian Peterson? They both had the world renowned orthopedist Dr. James Andrews do their surgery and they are both world class athletes receiving the best care. So why the difference on the field?
ACL rehab is a complicated process with no definitive protocol and time frame that works for every athlete. “When will I be back playing” is always the first question I get from my athletes. My standard answer is, “when you’re ready.” I have no idea how long it will take an individual to return. I’ve had pro players take a year or more to get back to their pre-injury level of play and I’ve had a high school soccer player return in 11 weeks. So, why such variability in return to play? There are many factors that influence return to play following ACL reconstruction. The key factors are surgical technique, biological healing, rehabilitation, and individual healing response.
Obviously, fast recovery requires good surgery. But even the best surgery doesn’t guarantee Adrian Peterson-like results. Less trauma caused by surgery, the less postoperative pain and swelling and hence a quicker immediate postoperative recovery. But this has little influence on overall return to sports.
We know that specific surgical procedures require definitive time frames for healing. ACL graft choice can affect early return to sport as patella tendon grafts heal faster in the bone tunnels than soft tissue grafts do (hamstring, allografts). Meniscal repair requires 3-4 months to be able to withstand sport specific forces such as running. Articular cartilage procedures can require up to 18 months to completely heal. Stressing any of these surgical procedures before they are healed is setting the patient up for a poor outcome.
Rehabilitation is a very important aspect of return to sports following ACL reconstruction. To recover the way Adrian Peterson did, you need a physical therapist or athletic trainer who is experienced in treating high level athletes. There is a fine line between pushing an athlete and doing too much. Harder is not always better, especially if it’s causing increased swelling. And obviously if you’re doing the same exercises as the knee replacement patient on the table next to you, you should find a new place to do your rehab.
Individual Healing Response
This is the key variable in rehabilitation. Why is it that three days after surgery some of our patients look like they never had anything done and other still have a big swollen knee at three months? Patients only recover as fast as their body will let them despite the best surgery and rehab. You can work as hard as Adrian Peterson but you still make take as long as Derrick Rose to fully recover.
How do we know when a person is ready to return to activities such as running and when they are ready to actually play in a game? ACL rehabilitation follows postoperative protocols or guidelines. These are either based on specific time frames (ie. running is allowed at 3 months), objective goals that must be met (ie. full range of motion and strength and no swelling to initiate running), or a combination of the two.
Time-based protocols are important when patients have procedures like meniscal repairs when there is a definitive time frame required for healing. They are ineffective when addressing return to sport and play as the either they under or overestimate the time required. It’s more important to base recovery on meeting specific objective goals such as range of motion, strength, balance, swelling, and pain levels. It’s also important that patients progress gradually, implementing sport specific activities as indicated (ie. shooting free throws, to jump shots, to movement with shots, to lay ups). Oftentimes we see that the athlete’s knee is 100 percent, but their fitness, confidence, and sport specific skills are not. I would imagine that this is probably where RG III is in the rehabilitation process.
There is concern about returning athletes to sports too soon after ACL reconstruction. The risk of re-injury or injuring the opposite knee increases as much as 10 times after ACL reconstruction. If there are any lingering deficits such as strength or balance this would predispose the athlete even more. So it is extremely important to return an athlete to sports when they have met specific objective goals and passed return to sport testing versus saying “It’s been 9 months since surgery, so you must be ready.”
So what’s the key to successful ACL rehab? It starts with a good surgeon, followed by an athletic trainer or physical therapist that is experienced in treating high level athletes, and it requires a lot of patience as sooner is not better. Just ask RG III.
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