ACL Rehabilitation Timeline: Month Nine and Onwards

Okay, athletes. The time has come for another MAJOR milestone in your rehabilitation training…

At your 9th month of rehab, you’ll be at just about the lowest point of risk for ACL failure and reinjury! (There’s still, of course, always some risk of injury, but you’ve rehabilitated to a point where your risk levels are approximately the same as they were before injury.)

In other words, your chance of safely returning to play is continuing to increase at an exponential rate. How fantastic is that?

Reaching month 9 is a huge feat to celebrate, but there’s some bittersweet news… you’re not exactly done just yet. There’s still a bit more to go for a truly safe return to sport.

And we know what you might be thinking; most professional athletes tend to return to sport before they even hit the 9-month mark, so why do you need to keep going well beyond it?

It’s a completely valid question to ask, and also one that requires a bit of extra context.

Statistics for Returning to Competitive Sport

Recovering from an ACL repair and returning to competitive play is entirely doable, but it’s an arduous process that takes lots of time for a proper recovery.

A good majority of high school or collegiate athletes rarely make a safe return to sport in under 9 months — not as a result of not working hard enough, but simply because 9 months is too soon for your body to be fully equipped to handle high intensity game speeds.

competitive return to playEven though many athletes have gone back to competitive play under 9 months, most of them sustain further injury not too long afterwards. In fact, research indicates that many athletes who have undergone ACL reconstruction surgery don’t actually return to their usual level of competition. This particular systematic review had involved over 5,000 participants up to 3-4 years after their procedures, and the data yields some pretty surprising numbers:

  • About 90% of athletes achieved normal knee function for both strength and ligament laxity
  • 63% returned to their pre-injury level of participation
  • 44% returned to competitive-level sport competition

Based on these statistics, roughly ⅓ to ½ of post-op ACL athletes never return to their previous level of competition. That’s a crazy high percentage, especially in the context of over 5,000 individuals!

However, that’s not something you necessarily have to fear — there are two main factors that often contribute to insufficient return to sport. Let’s break them both down to understand how you can sidestep the same issues, ensuring the longevity of your competitive sport career.

Why Don’t Many Athletes Return to Sport?

After months of rehabilitative training, you know by now that recovering from ACL surgery is a highly complex process to work through. It challenges you on both mental and physical fronts, and both aspects require deliberate attention and practice.

Unfortunately, many athletes fall just short of fully overcoming both — not because they didn’t work hard enough, but often because they aren’t aware of how deeply these barriers can impact their mentalities and movement.

Let’s unpack them one at a time...

Fear of Reinjury

As we’ve mentioned in previous ACL posts, fear can have a devastating impact on your rehab progression and training. (Our own physical therapists who have sustained ACL injuries in the past understand this experience firsthand, on top of the many ACL clients we’ve supported over the years.)

fear of reinjuryIt’s entirely understandable to be fearful; sustaining an ACL tear is a traumatic and painful experience, and that kind of emotional intensity can leave a deep imprint on your memory and movement.

Overcoming that fear and uncertainty takes some time to unravel, but the effort and time taken to reestablish confidence in your movement will make all the difference in your recovery. If you let that fear manifest, even if only passively, it can be a huge subconscious hindrance on making more significant strides in your progression.

Fear of potential pain or reinjury through training is especially prominent with sport-based, neuromuscular training. And this is what often impacts athletes the most — playing a high-level sport demands fast, subconscious action, but it can’t be executed well (or safely) if an athlete fears all the “what-if’s” of their next movement.

That’s why it’s important to begin addressing that fear early on in your recovery, starting around month 3 or 4. Although you’re still far from returning to sport at that point, it takes a lot of mental fortitude to regain confidence after a traumatic injury; unpacking those emotions early on will help you progress steadily through your recovery and eventual return to sport.

Lack of Specific, Neuromuscular Training

On top of coping with the emotional complexities of injury, many athletes are also put through rehabilitation progressions that aren’t as robust as they should be.

Although month 9 is typically the benchmark in which your risk of injury is as low as possible, you’ve only just achieved that level of safety. It’s important to continue training the same, lower extremity movement mechanics with higher intensity and speed, that way you’re continually building your way back to in-game speeds.

That being said, month 9 isn’t just the same training but harder. Once you’re this far into your rehabilitation, your focus shifts into specific neuromuscular training.

Many post-op athletes have difficulty initiating single-leg drills as a result of fearing potential pain or injury. Because this involves a combination of both the mental and physical fortitude necessary for rehabilitative progression, it’s especially important to begin addressing single-leg drills around months 4-6 to ensure sufficient progress to game speeds by month 9.

That’s where variable, sports-based practice is key. The specifics behind said training will vary depending on your individual biomechanics (and any remaining deficiencies). But, to give you an idea of what you may be able to expect, here are a handful of common training examples we see in many athletes:

sports-based practice

  1. Sprint to deceleration while catching or kicking a ball
  2. Sprint to lateral shuffle while catching a ball
  3. Sprint to pull-up jump shot
  4. Agility hurdles (or the agility ladder) while playing catch
  5. Jumping off of 1 foot while your therapist pushes in the air with a ball (requires you to land softly and with good form)

Again, these are just a few examples of how you may practice added complexity and specificity in your training. The unpredictable nature of throwing, catching, jumping, changing direction, and reacting to perturbation is what trains your knee to be comfortable and confident during game speed situations.

Many athletes also tend to struggle with normalizing their impact forces with running and jumping. For the most part, this difficulty is usually a result of insufficient range of motion with both hip and knee flexion while performing sports-based activities. The combination of increased impact forces and insufficient joint flexion can lead to poor shock absorption and longer-term gait deviations, so it’s important to focus your training on long-term knee health and function. (But hey, that’s why the latter half of your rehab will address those common issues with range of motion! It just takes some extra diligent work and practice to ensure it truly helps prevent long-term issues.)

Return to Sport Testing (Take Two!)

Yes indeed — it’s time for your second RTS!

As you probably remember, your first round of RTS testing was to assess the level of your strength and motor control training at that point. That data then set the stage for your rehabilitation progression from months 6-9.

Now’s the time in your training where you get to retake the test at a more robust level, truly challenging your development of speed and power. All the assessments you did previously will now be done at or near full game speeds (of course, as long as your physical therapist has cleared you for that level of testing based on your overall progress and mental readiness).

You’ll also likely go through some additional testing, particularly for your performance with single-leg max jumps and crossover hops, as well as a running analysis to pinpoint any potential issues with shock absorption or power generation. The main keys to this second RTS is to check your hip, knee, trunk, and pelvic control, all of which contribute to your overall shock absorption and serve as key biomechanics for powerful, controlled sports motions.

Granted, not every person has access to a human performance center, so it’s important to have some form of data measuring the quality of your movement and skill. Have your physical therapist record your sport-based movements with high speed video, that way you have a foundational understanding of your form and movement control.

Though it may seem meticulous to go through two rounds of testing, that’s really the point of it: to be thorough and accurate via hard, measurable data. And once you combine that movement data with your mental and physical fortitude, you’ll have your sights set on completing your training and getting back to your sport, the right way.

Onwards and Upwards — and Back Onto the Field!

And that’s a wrap on our ACL rehabilitation series! (Huzzah!)

Of course, you’re not officially done with the actual rehab part, but you’ve already made it this far; there’s no stopping you now, right? You’re only going to work harder and get better from here, and the remainder of your training is all about nailing down the details to your individual, biomechanical needs.

Whether you’ve been following along every month, or if you just popped in to get a peek into the process, we’re glad you took the time to read up on one of the most common and debilitating injuries for ground sports. Half of the battle to recovery is in the knowledge alone, and the other half 

So this is as far as our blogs take you — you got this, fellow athletes. Be strong, and be confident in the resilience you’ve built in your body!


Kevin

Kevin Vandi, DPT, OCS, CSCS

Dr. Vandi is the founder of Competitive EDGE Physical Therapy — with his background in physical therapy, orthopedics, and biomechanics, he is a highly educated, compassionate specialist. Using state-of-the-art motion analysis technology and data-driven methodologies, Kevin has assisted a wide range of clients, from post-surgery patients to youth and professional athletes. When he isn’t busy working or reading research, he spends his time with his wife Chrissy and their five wonderful children, often enjoying the outdoors and staying committed to an active lifestyle.

ACL Month 9