Return to Play After ACL Reconstruction
by Arun Ramappa, MD

Injury to the anterior cruciate ligament (ACL) is one of the most common knee injuries sustained by athletes.1 Hearing news of this injury is often overwhelming for athletes as they know they will have to put their recreational or competitive careers on hold to allow for surgical intervention and rehabilitation. This news is even more frustrating when they are told that their earliest return to sport is months away.

Historically, restoration of an ACL injury was slow and often career ending. Many athletes who injured their ACL would continue to play and further damage their knees until the injuries were beyond repair. In addition, early efforts involving casting methods and repair of the torn ligament provided poor patient outcomes, and were not very successful.2 Today’s gold standard of ACL reconstruction, essentially a replacement of the ligament, has allowed for improved patient outcomes that permit return to sport faster than ever before. But are we pushing the limits of recovery?

As we have improved surgical techniques and rehabilitation programs, the time for return to sport has shortened. Some patients, such as professional athletes, have been returning 6 to 8 months post-surgery,
though there is considerable variability. These quick recoveries are often highly publicized and therefore have a great impact on the public’s beliefs about recovery.

Recent research has shown that the knee does not fully recover from this injury until two years post-surgery, especially in younger athletes. After two years, basic biological and functional measures including graft
maturation and neuromuscular control are resolved and reestablished.3 If patients return too quickly, complications, such as a second ACL injury, are more likely to occur. Research has identified that second ACL injuries are six times more likely within two years after surgery, in the adolescent population and five times more likely within the female adolescent population.1 This evidence points to a key fact for proper ACL recovery: rehabilitation takes time, especially in younger patients.

It is important to note that return to play recommendations are in evolution based on this newer research and they will differ from case to case depending on the patient and their efforts towards recovery. During ACL recovery, enrollment in a rehabilitation program is essential and patients will work with therapists and physicians to construct an individualized program.4

The take home point is that a specific time point after surgery, such as 6 or 8 months, should not be used to determine return to play. Rather, it is essential for patients to establish their appropriate recovery plan with guidance from their physicians and therapists to ensure full recovery.

For more information about return to play click the link below…

Return to Play Information

1. 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. The American Journal of Sports Medicine. 2014. 42(7), 1567-1573. doi:10.1177/0363546514530088.

2. Warren, RF. Anterior cruciate ligament (ACL) injuries—then and now. Retrieved from 2012.March 16.

3. Nagelli CV, Hewett TE. Should return to sport be delayed until 2 years after anterior cruciate ligament reconstruction? Biological and functional considerations. Sports Medicine. 2016. 47(2), 221-232. doi:10.1007/s40279-016-0584-z.

4. Ellman MB, Sherman SL, Forsythe B, LaPrade RF, Cole BJ, Bach BR. Return to play following anterior cruciate ligament reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2015.23(5), 283-296. doi:10.5435/JAAOS-D-13-00183.