ACL Injury and Reinjury – A Concern for the Parent of an Athlete

Imagine for a moment that you are the mother of a talented high-school basketball player. He’s currently a junior, is passionate about basketball and motivated to pursue it as far as he can. But, he’s just suffered a second ACL tear and reconstruction on his other leg – just three months after he was released to play again following his first ACL reconstruction! Now he’s recovering, and nearing the point where his surgeon may release him to play again, and you’re feeling nervous. In the last year he’s had major injury and surgery on both of his knees, and you know he’s at an increased risk of re-injury to both of them, let alone what he might feel like as he gets older due to earlier onset of arthritis. How can you help him avoid re-injury and reach his full potential as a player?

Sam – ACL Injury and Surgery x2 – Where to Turn?

This was the situation an Ardmore mom was in when she first called me a few months ago. Her son, Sam, is a junior at Ardmore High School. In August of 2016, he tore his left ACL and meniscus while playing basketball, and had bone-patella-tendon-bone (BPTB) ACL reconstruction. He was released to return to play about 6 months after his surgery, but only 3 months later (9 months post-surgery) suffered a right ACL tear. Sam’s mom started researching what could be done this time to help Sam recover better and stay injury-free. That’s when she found the information on my website about how the landing error scoring system (LESS) can identify those at risk of ACL injury and better help reduce injury risk, and she gave me a call.

This diagram shows a) normal lower extremity (LE) position when standing on one leg. It shows increased hip adduction due to weak hip abductors (b). It shows compensation leading to a valgus deformity and force (c)

When I first examined Sam in September of 2017, he was 3 ½ months post-surgery and had been receiving PT treatment at another local clinic. Although he’d been going to therapy twice a week, he was much weaker than I expected and was in no position to be doing the LESS screening. He had not been doing much home exercise as part of his previous PT treatment and had not done any significant single-leg weightbearing work. His single leg squat mechanics were quite poor, with his knee collapsing in and his pelvis dropping (see diagram from previous blog article showing how this risks ACL tear). My manual tests showed his quads and hamstrings to be strong; this was confirmed a week later with a machine-based test (isokinetic dynamometry) that his doctor ordered before releasing him from his care. But just because he was released from the doctor’s care, Sam’s mom knew she didn’t want him to just jump right back into playing basketball; in order to avoid re-injury, a more careful and controlled return to sport was needed. Below, I will outline the specific plan of care that I took Sam through to improve his strength and biomechanics prior to giving him the go-ahead to return to playing basketball below; but to understand this better I first want to go into a little more detail about ACL tears and reconstructions as these are important to understand as part of this process.

Time is a Healer, But How Long?

Many patients are queued to expect a return to sport at 6-months, mostly because a fair number of professional athletes are seen to do this. Friends who’ve undergone similar injuries, the media, and pressure/desire to not miss a playing season reinforce this trend. However, even a fair amount of professional athletes suffer re-tears – and they have many resources at their disposal that students and the general population just doesn’t have – such as time and access to top-notch PTs, trainers, gym equipment, and doctors. Since student-athletes aren’t surrounded by such a team of experts and resources, we have to assume their recovery should take longer. However, it’s also not just a matter of adding recovery time. Time alone doesn’t take into account progress in strengthening and improving biomechanics and how they interact with a healing knee. Instead of just waiting an arbitrary amount of time, there are objective criteria that we can use to help gauge progression and readiness to return to sport.

To understand this better, let’s delve a little deeper into ACL tears and reconstructions. I’ve written before about the epidemic of youth ACL tears and how they can be prevented. The ACL is an important ligament that provides stability and controls rotation at the knee. When it tears, people can experience instability on that leg; it can be a devastating injury physically and psychologically. There are two options to treat an ACL tear: reconstruction or rehab. Most of the time for athletes under 40, reconstruction is the option of choice. I use the word ‘reconstruction’ vs. ‘repair’ as there is not yet a proven way to repair the remaining ACL. (There is some promise in the ACL BEAR Trial at Boston Children’s Hospital.) Instead, the surgeon must construct a new ACL. Over the years, various tissues have been used, some less successful (synthetic) and others more successful (ligament and tendon) for the graft. The non-synthetic, ligament and tendon, grafts can either be from the patient (autograft) or a cadaver (allograft).

In competitive athletes under 40, the gold standard is considered to be a bone-patella-tendon-bone (BPTB) autograft – this is the surgery that Sam had after each of his tears. Some surgeons will use hamstring grafts, and there is also a development towards quad tendon grafts (check out this blog by PT and recent ACL victim Laura Opstedal on her decision process around graft choice.) In the case of a BPTB ACL reconstruction, the surgeon has to drill a tunnel through the tibia and femur in the angle/plane of the original ACL. They then place one bone end of the graft in the tibial tunnel with a screw and the same to the other end in the femoral tunnel. There is great skill in this surgery, and in the research, they are always trying to move towards a reconstruction that more closely mimics the anatomy of the original. Outcomes can be poor when the reconstruction angle is too vertical, the ligament is too tight or lax, or for many other reasons, so surgeon selection is important!

Once a patient has the surgery and comes out of the operating room, they are not immediately able to do everything they want. The first thing that patients typically notice is feeling like they cannot fire their quads, which gives a huge feeling of instability. As swelling settles and the quad gets stronger, the knee starts to feel more normal. I find that often younger patients recover their quads quicker and feel back normal sooner than others. However, that does not mean that the knee has finished healing or that it’s ok to go back to playing sports! Something very important and amazing is happening, and we need to protect the knee while it does!

While the bony part of the BPTP heals pretty quickly (like a fracture), the tendon portion of the graft dies! Yes, it dies, but then it starts to be infiltrated with new blood vessels and nerves, and here is where it gets cool. The graft starts to take on the structure of an ACL! Yes, from day one, there is a process of death of tendon cells and then growth and development of ligamentous cells. We call this process ligamentization and during it we have to strengthen the knee and the hip, gain control of the leg, BUT ALSO protect the maturing ligament. When the ligament is not well protected before it has matured, there is a chance it will retear. This is a big topic of research¹ and debate as the timeframes of this maturation process vary in the research.

The results of Clae’s et al Systematic Review – Showing uncertainty in length of time for the ligament to mature.

There is certainly a wish to return to sport quickly due to various reasons and pressures. However, if you return too quickly you risk retear. A study in 2012² found that a young athlete who returns to sport within 1 year is 15 times more likely to suffer a second ACL injury than a healthy athlete with no medical history of a knee injury. The same group in 2014³ published further findings that elevated risk remains evident within two years of returning to activity when an athlete is approximately 6 times more likely to sustain a second injury than an uninjured counterpart. This has led this group of authors to suggest⁴ we should wait till 2-years post ACL surgery for return to sport! I suspect that two years may be overly conservative for most people, while 6-months will be too soon for the majority; in reality, recovery time will be dependent upon the individual and their progress.

How Sam Followed And Trusted The Criteria

Keeping this in mind, I stressed to Sam and his mom the importance of a criterion-based approach to determining when it was safe for Sam to return to basketball, and provided him with a set of exercises and goals for us to reach. At each appointment, I was testing and measuring several key metrics that helped to show me how his strength was progressing and whether he had met criteria to move to the next progression. As he strengthened, I progressed his home exercises to keep him challenged and moving closer to reaching his goals. After 4 visits spread over three months (6 months and 10 days post-surgery), he was ready to be tested against what would be one of the final criteria for return to sport: the Cincinnati hop test. Two of the four hop tests are shown below from one of Sam’s appointments:

But here was the twist with Sam: normally for the hop test we want the performance of the injured leg to be within 90% of the uninjured leg. But in Sam’s case, he had recovering ACL’s on both knees! Thankfully, some recent research⁵ provided helpful benchmarks – They found normative values for basketball and football players for the hop tests at both high school and collegiate levels for males and females. As you will see in the chart below, Sam performed pretty well, being within the average of the high school athletes for some of the hops (2/4 on right, 3/4 on left) However, I wanted him to perform better, so I progressed his exercises and training and at the next appointment he was much better – close to the average male hop test for a high school athlete. He was still having some consistent right knee pain and left shin splints, and I was still concerned that he was not ready to return. I could see Sam was disappointed with this, and he felt strong, so I used a further test to help illustrate my concerns: he was to do single leg squats up and down from the chair. On the left leg he could do 23, and on the right only 12. Research⁶ shows that having the ability to do 22 or more after ACL surgery correlates with significant improvement in quality of life 3 years out from surgery. So, he was on the cusp of return to sport, but he still had weakness that could negatively impact his life. I saw him again in late January (nearly 8 months post-surgery) and he did much better in hop testing.

Further Testing to Make Sure Sam Was Ready to Return to Sport

He still had some transient knee and shin pain, which gave me a slight pause, but with only two games left of the season in which he will likely see minimal playing time, and would be similar to recent practice, he had my blessing to return. This turned out to be true when I saw him for follow-up in March, and he was still having a little pain after practicing for longer periods. The hop tests showed good power and control, but he was still lacking endurance. To help illustrate this I had him do a hop test where you hop side-to-side between two points 40 cm apart for 30 seconds. On one side Sam managed 36 and on the other 32. The aim is to be within 90% of the other side and close to the norm (55 for males, 41 for females)⁷.

To highlight this further, we initiated some drills using an app called Clock Yourself which showed he had good reaction and control, but he found endurance challenging. He was due to start a development ball program and I very strongly recommended that he needs to continue to build strength, endurance, and should be a great position to enjoy playing development ball through the spring and hopefully have a standout season as a senior. Should he do these things, he gives himself every opportunity to play collegiate basketball, but more importantly to have as healthy a knee as possible as he moves through life.

What Huntsville And Madison Parents And Athletes Need to Know!

Navigating an athletes’ return to sport can be a challenging, evolving, multifactorial equation. Part of the equation is made easier by research such as I refer to in this and other blogs. The patient’s outlook, the support they experience from their family, and the level of trust they develop with their healthcare providers are also key factors. In Sam’s case, he had supportive parents and we developed trust from the first session. One part of the equation that can be challenging depending on the therapist is an understanding of the patient’s sport and relevant professional experience. I have been fortunate to have treated collegiate and professional basketball players in my career, so I knew the levels that Sam needed to achieve if he wanted to have the opportunity to go down that route.

If you are looking to return to sport after injury or surgery, research your rehab options and who you will work with. I have worked with high school, collegiate, and professional athletes in various sports, with injuries from ACL to labral repairs, to rotator cuff repairs. Please call me if you have questions that I might be able to answer or if you want to find out how to work with me.

References:

1. Claes S, Verdonk P, Forsyth R, Bellemans J. The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med. 2011;39(11):2476-83.
2. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral anterior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport Med. 2012;22(2):116-21.
3. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567-73.
4. Nagelli CV, Hewett TE. Should Return to Sport be Delayed Until 2 Years After Anterior Cruciate Ligament Reconstruction? Biological and Functional Considerations. Sports Med. 2017;47(2):221-232.
5. Myers BA, Jenkins WL, Killian C, Rundquist P. Normative data for hop tests in high school and collegiate basketball and soccer players. Int J Sports Phys Ther. 2014;9(5):596-603.
6. Culvenor AG, Collins NJ, Guermazi A, et al. Early Patellofemoral Osteoarthritis Features One Year After Anterior Cruciate Ligament Reconstruction: Symptoms and Quality of Life at Three Years. Arthritis Care Res (Hoboken). 2016;68(6):784-92.
7. Gustavsson A, Neeter C, Thomeé P, et al. A test battery for evaluating hop performance in patients with an ACL injury and patients who have undergone ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2006;14(8):778-88.