How Do I Know If I Am Ready to Return to Sport After ACL Injury?

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There are several factors that one must consider as they near return to play after an ACL injury and it is important to note that just because your surgeon has cleared you for return to sports does not mean that you necessarily have the functional strength and movement proficiency that you need in order to return safely to the field of play.

Below are the most important factors (not in any particular order) to consider before you return to competition.

Do you have the prerequisite strength needed to perform your athletic activities safely? Throughout your rehab process you have been working on building strength in certain areas so that your muscles may best support your joints during the stressors of unpredictable sports related activities.
Areas that you should be working primarily on throughout your rehab process include the back of your legs (hamstrings) and buttocks (glutes), abdominals (core), your lateral hips and quads. Your physical therapist should be hitting these areas hard in order to properly prepare you for return to play when appropriate.

Neuromuscular Control
Even more so than strength, neuromuscular control and having the proper movement patterns may dictate whether or not you reinjure yourself in the future. Being able to move efficiently and relatively symmetrical is an aspect that many coaches, therapists and surgeons overlook when clearing an athlete for return to play.
One predictive indicator of future injury is do your knees migrate inward into a valgus position during squatting, jumping and hopping activities. In other words do your knees fall into a knock-kneed position during dynamic knee flexion activities? If so, you may be predisposed to re-injury. Make sure that when squatting, lunging, hopping, jumping and running your knee stays out over your little toe and facing the direction that your toe is facing. This will ensure that you are properly set up to return to play with a reduced risk of re-injury.

Some individuals are structurally predisposed to ACL injury. Some individual’s hips are a little bit wider or their hips tend to internally rotate. Others may also be structurally knock-kneed (knee valgus) or have flat, over-pronated feet that cause their knees to fall in toward each other.
These are the things that we cannot always control but your therapist can strengthen specific muscles and movement patterns in order to help prevent a propagation of these predisposed tendencies.
Unfortunately it may often be difficult to affect changes in structural predispositions however as a therapist or strength coach it is our job to add strength and address neuromuscular control. Your therapist or coach should focus their programs on building the prerequisite strength to better control and support your limb movements to decrease stress through the ACL as it stops the forward translation of your tibia (lower leg bone) on your femur (upper leg bone) during activity.

Ask yourself, do you feel like you are ready to return to play? This generally goes both ways for patients. On one side of the spectrum many athletes feel that they are ready to return to play prematurely and feel that the therapist or strength coach has been holding them back.

Juxtaposing this feeling is the athlete who is hesitant to return to play. These athletes are generally apprehensive about getting back on the field or court at full speed. For instance take Derrick Rose of the Chicago Bulls. His physician and trainers cleared him to play earlier this year though he did not feel that he was ready to return at a high level of play. As a result he missed his teams entire season and playoff run. While physically he was structurally sound and stable enough to play, psychologically he did not feel ready to play at a high level.

This is why it is important that your rehab involves logical progressions and unpredictable sport specific situations in order to help you gauge your readiness for return to play and to help you build the confidence to return to the field of play.

ACL injuries are devastating injuries but by no means should they be career ending. Making sure that you and all members of your rehab team (physician, therapist, strength coach and trainer) are on the same page and addressing each of the above factors you will be well on your way to returning to the field in a timely and safe manner.

Contributed by Dr. Jon Herting, DPT


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