”Yeah, I’m fine. I just tore my ACL.”
I was skiing, doing tricks off jumps. I’ve been skiing since I was 3 years old, could spin circles down double black diamond mogul fields and bomb through the trees on my ”Tele’s”, so this was nothing new. I lived for this! But I made the fatal mistake of saying ”one more run”, which if you’re a skier, you know never to say! Making that last run, I landed a jump and was sliding sideways and felt my knee do a little ‘jiggle’ which would perfectly recreate the ACL stress test I had learned in class the week before…
I knew immediately what had happened. And I knew it would be over a year before I would be 100% back to full sport activity. It would cost thousands of dollars. And I’d be at risk of a re-injury forever.
Almost everyone knows someone who has been through this. The epidemic is escalating, especially among young female athletes who are 4-6x more likely to have this injury than male athletes. To make it worse, many of them re-tear their ACL within a year of surgery. It’s about time that we start preventing these injuries. And it’s going to take more than 9 months of physical therapy and a knee brace!
Read on to learn:
- Why this epidemic is happening
- My client’s optimal recovery
- How you can prevent this for yourself, your kids, and your team
ACL Injury Causes
The most important question to understand why ACL tears have become so prevalent is to ask, ‘what changed?’
There have been a few major changes in recent years that have led indirectly or directly to higher ACL sprain rates. This is not an exhaustive list, but should provide some ideas for prevention. Most of these focus on female athletes because they are at greater risk of injury.
- Girls are playing sports more! This is simple, but true. And ultimately, young girls are not as strong as young boys and so are at greater risk of injury.
- Sitting: increases hip flexor tightness. Sitting in class, work, cars etc tightens the hip flexors which can lead to anterior pelvic tilt, which causes internal rotation of the legs (femur/knee/tibia).
- TURF: fields are becoming more and more common. Look at the NFL. Since the introduction of turf fields, the ACL injury rate has exploded. The same can be seen in high school and college sports. The combination of cleats and turf increase traction to a point where the ankle and foot cannot rotate to protect the knee.
- Repetition: studies are showing that ACL tears occur most often due to knee internal rotation during non-contact pivoting. Research indicates that the injury is often the result of ”10,000” repetitions that weaken the ACL over time. This means that correcting body mechanics in young athletes to reduce the number of internal rotations could prevent ACL tears.
- Hamstring: Studies also show that weak hamstring eccentric strength is correlated with ACL sprains and even doubles the rate of re-injury, post surgery. The Hamstring and ACL work together to prevent anterior Tibial translation. This indicates that stronger hamstrings could prevent ACL injury.
- Implement core stability, strength and agility exercises
- Release hip-flexor muscles and strengthen glutes before training
- Reduce ground traction by replacing cleats with turf shoes (on turf fields)
- Correct knee alignment during landing, pivot and jumping motions
- Increase hamstring eccentric strength
*These can be applied to any sport team but will be exponentially more beneficial for young female athletes.
Rehab and Prehab
The following outlines the program and results of a successful ACL surgery recovery. This is a general guide, not a personal prescription. Consult with your Doctor if you have any questions. The exercises outlines can be used to test and ‘Prehab’ athletes to prevent this injury.
My Client’s Story
This teenager soccer player tore her ACL from contact with another athlete. She had surgery and came to see me while doing physical therapy 2x/week. She worked with me for 6 months 2-3x week while continuing physical therapy. Then dropped to 1x/week for 6 months and then about 1x/month for another 6 months.
At 9 months, she was cleared to play soccer. This seems to be the usual return-to-play timeline for physical therapists. However, appropriately afraid of re-injury, she came to me for testing and we discovered that she could barely do one-foot hops and was no-where near close to equal strength in her surgery leg.
When to do Physical Therapy: From my observations, the standard physical therapy return-to-play protocol for and ACL surgery is about 9+/- months. I believe that early return-to-play has resulted in a very high rate of re-injury. I don’t want to attack physical therapy entirely, because I know they are restricted to a limited number of visits by insurance companies. And, they are not generally trained to return athletes to play. Physical therapists specialize in returning people to normal activities after surgeries and other injuries. Athletic Trainers specialize in returning athletes to play at full (or greater) ability than pre-injury. The best solution for an injured athlete is to work both with a physical therapist AND an Athletic Trainer. (I also refer my clients to massage therapists, chiropractors, and other specialists.)
To put this in perspective, Tom Brady (Patriots Quarterback) returned to play at 9 months and he had the top trainers and therapists in the world, working with him every single day… And we’re supposed to believe that a high school girl doing physical therapy twice a week will recover in the same period of time? I just don’t see that happening.
Luckily for this client, she continued to work with me for another 6 months to develop strength and explosive power. The results speak for themselves. She has been playing soccer with a knee brace since being cleared in December (10 months ago). After re-testing explosive power and strength, I have cleared her for full activity and she is weaning off her knee brace. Anything can happen, but I feel confident that she will be able to prevent re-injury.
*Every athlete is different and will recover at different speeds. Some may recover faster. Some slower.
See the Results
Things to notice:
- Knee valgum (knee alignment inward)
- Arch collapse
- Foot external rotation
- Quad dominant squat – bending the knee only instead of ‘sitting back’ with the hips
- Weight shift away from injured side (2 leg squats)
- Surgery-Leg Atrophy / Loss of Muscle
- Notice that these alignment issues are present even on the non-injured leg, indicating a pre-disposition for injury. These movement patterns are prevalent among the majority of young female athletes.
Fast Forward 3 Months (6 Months Post-Surgery)
Things to Notice:
- HUGE improvement – Great depth and alignment for the 2 leg squat
- Slight knee valgum – right side
- Atrophy Right Leg (Muscle Loss)
- Note: She is wearing shoes in these photos, but barefoot testing showed no difference.
Cleared for Full Activity Without Brace
These videos demonstrate my full return-to-play testing protocol. I believe that most high school and college female athletes would fail these even without history of ACL injury.
Thank you for reading this. I know it was long. If you take away only one thing, it should be that this client was cleared for full participation at 9 months. At the time, she could not perform the ‘pistol squat test’, ‘side-side hop test’, ‘pivot test’, ‘bounding test’, and almost fell to the ground attempting the ‘sprint to bounding test’.
This should be a huge red flag for her physical therapist and physician who cleared her. I would have classified her as a ‘high-risk’ candidate for re-injury. Now, she is near equal in strength, flexibility, balance, speed, and power. The last part of her program is to redevelop coordination without the support of the knee brace. She is doing this by practicing simple dribbling skills with a soccer ball.
I have gone through ACL rehabilitation myself, and just like this athlete, I came through it faster, stronger and more athletic than I was before injury. This is 100% thanks to my trainer and Mentor, three-time Olympic Coach Tom Barbeau. He gave me a great gift when he taught me how to recover from this type of injury with the Burdenko Method. I consider it my obligation to pass it on. As such, I would love to give a free private consult or presentation to your team on ACL injury prevention and recovery. Just comment below and fill out the Contact form on this website.