ACL Rehabilitation in Petaluma: How Athletes Return to Sport
Introduction
The Anterior Cruciate Ligament (ACL) is one of the most well-known and feared injuries in all of athletics. With the prevalence of youth sports, trail running, and snow sport enthusiasts in Petaluma, Rohnert Park, Santa Rosa, and surrounding parts of Sonoma County, residents here are no stranger to ACL injuries. These sports put increased stress on the ACL due to the cutting and pivoting that is present in each of them, especially in field sport athletes.
Typically, the injury requires anywhere between 9-18 months to rehabilitate correctly. While simple daily functions are typically restored by month 6-7, truly returning to sport-level fitness and preparation requires increased time. The vast majority of people experiencing an ACL injury don't simply want to recover, they want to return to at least the level of strength they had prior to their injury. That's where injury rehabilitation can make or break the situation. Without getting to this level, these highly active individuals will be at higher risk of injury when returning to their sport or activity. In fact, nearly 20% of those who undergo an ACL repair will re-tear that same ACL in the future.
For athletes in Sonoma and Marin County, there are a few critical factors necessary to consider to mitigate this risk, and ensure appropriate rehabilitation. In this post, we'll cover the specifics of ACL injuries, how to determine appropriate rehabilitation, and knowing when you're ready to return to sport.
What is an ACL Injury (Symptoms, Causes, and Treatments in Athletes)
The ACL is one of the primary ligaments responsible for stabilizing the knee during cutting and pivoting. Specifically, it's responsible for preventing excessive anterior translation of the shin bone (tibia) on the thigh bone (femur), as well as resisting rotational forces between these two bones. When an athlete quickly decelerates, or changes direction, the ACL can be stressed, leading to its injury. Proper recruitment of the muscles is highly preventative for ACL tears, but sadly, this is often overlooked in youth and adult sport. Nearly 70% of ACL injuries occur in a non-contact manner, suggesting that they are largely preventable.
When an athlete experiences an ACL tear, they will almost always feel a "pop", followed by immediate swelling. While they may be able to put weight on the leg, and walk with mostly normal mechanics, any time lateral or rotational movements are introduced, they will feel a degree of instability in their knee. This quickly leads to muscle atrophy in the quadriceps, along with loss of range of motion of the knee.
The most common sports at risk for ACL injuries include soccer, football, basketball, volleyball, skiing, and even trail running/hiking. As mentioned above, these sports require pivoting, twisting, and rapid decelerations, oftentimes unplanned or in response to another player or unsuspected terrain. When knee injury rehab in Petaluma doesn't cover these movements, future injury risk is increased.
Why ACL Injuries Happen (Especially in Athletes)
As discussed above, the vast majority of ACL injuries occur in a non-contact manner. This involves a rapid deceleration of the athlete, placing increased stress on the musculature and ligaments of the lower limb. While we can't draw conclusions about contact-related ACL injuries, we can with certainty identify the factors that lead to non-contact ACL injuries in athletes.
The underlying mechanism of the injury is often due to poor deceleration mechanics of the athlete. These poor deceleration mechanics often lead to valgus collapse or hyperextension of the knee. A rapid stop, rather than a more complete absorption force, leads to a sharp increase in the stress placed on the ACL. In simple terms, we'd describe this as using the joint to stop movement, rather than the muscles. This brief moment of movement collapse leads to a compromised joint that will almost always require surgery to return to sport.
As we alluded to previously, there are a number of strategies present for preventing ACL tears, with great research to back up their efficacy. Programs that sufficiently address strength of the hips, quads, hamstrings, and feet are paramount to prevention efforts. But this isn't enough - any prevention program must also include training on poor landing mechanics, reactionary movement stresses, and handling high forces over repeated durations, so as to prevent fatigue-related breakdown in mechanics.
Unfortunately, in Petaluma and surrounding Sonoma and Marin Counties, there is a lack of resources and education for athletes on how to incorporate these principles in their training. Rather, more time is spent playing the sport to improve technical skill, which actually compounds the risk factor for athletes. Because these athletes are learning to be faster and more agile through skill training, they have outpaced their body's ability to handle the forces produced during sport. Performance training for athletes is needed to ensure their bodies are capable of tolerating this workload.
Other factors also play in to injuries - there is sufficient data to suggest that turf playing fields have higher injury rates than grass surfaces. With the majority of playing fields in Marin & Sonoma County being turf, or poorly maintained grass fields, our athletes are at heightened risk for injury.
How Long Does ACL Rehab Take?
The answer to this question depends largely upon several factors - the severity of the injury, the type of surgery that was performed, the presence of other tissues being injured, the time to get into surgery, and the sport and level the athlete aims to return to, among others.
In general, a timeline of 9-18 months is typically most accurate for predicting successful return to sport. Many people suspect that they could return to sport sooner than this, perhaps in the same timeline as a professional athlete who did so in less than 9 months. This wouldn't be wise though, as professional athletes have essentially unlimited resources, along with higher incentives for returning to sport before they are fully prepared to do so.
There are 3 distinct phases to returning to competition - in the first phase, the athlete is aiming to regain as much range of motion and strength as possible, while also normalizing walking mechanics and balance. In the second phase, the athlete begins to return to running, along with adding in more complicated movements. In the final phase, the athlete is able to return to participation and practice in their sport before moving into actual game environments.
Common Mistakes People Make After an ACL Injury
When considering the high degree of re-tears, we can confidently say that many of these are not due to bad luck, but rather a lack of preparation and completeness in the rehab process. The following are some of the most common mistakes we see after an athlete undergoes an ACL repair.
Mistake #1: Rushing The Timeline
"If that NFL athlete got back to sport in 7 months, so can I" - every athlete we've ever encountered.
Sadly, this isn't true. There have been thousands of articles related to ACL rehabilitation, and all are pointing in the same direction. The safest timeline for return to sport is in the 12-18 month range. This is not what athletes want to hear, and so we put blinders on try and get back quicker. Remember though, re-tear rates are as high as 20%. When rushing back to sport, consider that another injury could keep you out for 12-18 months. Let's make sure we get it right the first time.
Mistake #2: Rehab focused only on Range of Motion
Much is made about regaining the range of motion of the knee - specifically flexion and extension - following an ACL repair. This is critical, especially in the first 2 months after the surgery. But range of motion is truthfully the bare minimum of what is required of the joint. Failure to focus on strength and power, along with deceleration mechanics, is a sure-fire way to end up back in the surgeon's office.
Mistake #3: Skipping Strength & Power Development
Seeing a trend here? Robust strength training, through structured strength and conditioning programs, is critical for safe return to sport. The most important areas to focus on are the quads, hamstrings, gluteal muscles (maximus and medius), calf, and the intrinsic muscles of the feet. Additionally, athletes should ensure that they have sufficient core strength. Weakness in each of these regions of the body has been linked to increased risk of future ACL tear, and thus must be addressed during an ACL rehab.
Mistake #4: Rehab Based on Timelines, Not Objective Testing
We could talk about this for hours. Basing your rehabilitation and return to sport off a timeline is at best, misguided. At worst, its unethical. Athletes heal at dramatically different rates, and the idea of having a standard timeframe for recovery is simply a gross misrepresentation of the healing process.
We gain clear objective data through return-to-sport testing, allowing us to know when an athlete is ready to return to sport. Testing their strength, power development, braking forces, speed, agility, reactiveness, and balance are all required to ensure an athlete returns to sport safely. Unfortunately, very few clinics are set up to do this well, especially in Petaluma and the surrounding areas of Marin & Sonoma County.
If your ACL rehab isn't testing these data points on you, and you plan to return to sport, then you are flying without clear vision.
Mistake #5: Stopping Rehab Too Early
As we've mentioned above, rehabilitation must cover a high degree of sport specificity to safely allow for an athlete to return to their sport. The speed, cutting, pivoting, jumping, and landing of sport must be stressed during the rehabilitation journey. This is often cut short for many reasons - including lack of equipment, lack of knowledge from clinicians, and failure for insurance to reimburse this portion of care.
But to miss these portions of the rehab journey are to fail the overall approach needed to safely return to sport, as well as to come back to sport as a stronger overall athlete.
Even after an athlete returns to sport, continued rehabilitation is necessary. We shouldn't be letting our athletes drive off the lot with a used car and wonder if they'll run into problems. Instead, routine check-ins throughout the return to sport period ensure that they continue to progress well, and avoid any flare-ups that come with he increased workload. When considering the high degree of re-tears, we can confidently say that many of these are not due to bad luck, but rather a lack of preparation and completeness in the rehab process.
How Performance Rehabilitation Solves the Problem
Most athletes will return to a pain-free life around 6-7 months. This is represented by the ability to do most of the activities they would in their life, including jogging or even going for runs. This time frame is also the area where we see the largest drop off in rehabilitation - discharges often occur here, with a loose plan for returning to sport.
This is not the case with performance rehabilitation. Rather, the goal is far beyond being pain-free. Instead, it's to ensure that the athlete is performance-ready.
This is done through rehabilitation that prioritizes strength development, force production, plyometrics, change of direction, reactive drills, and sport-specific conditioning and movement patterns. Objective testing through the use of dynamometry (strength measurement) and force plates (power production and braking capabilities) is a prerequisite for returning to sport. Unfortunately, few clinics in Petaluma, Rohnert Park, or Santa Rosa have access to this kind of technology, leaving athletes to fend for themselves or make judgments without data.
Performance rehabilitation is the bridge that brings together rehabilitation and training/sport performance. Without return to sport rehabilitation, athletes end up stuck in the 'not ready but feel good' area. We often refer to this as the danger zone, as it is the most common stage of rehab where re-tears occur.
How BaseCamp Performance Co. Approaches ACL Rehab
We've put together our own ACL Rehab Protocol, referencing protocols used around the world at the highest levels of sport, the latest research in the field, and in combination with the years of clinical expertise we have in treating these injuries.
Our protocol follows this simple, but robust pathway:
Step 1: Evaluation
When athletes come in for their evaluation following an ACL injury, or repair, we must first assess where they are at. Of course, we want to understand where their injured knee is at regarding strength and range of motion. But we also must assess their hip and foot strength on the injured side, their strength and range of motion on their uninjured side, their core and upper body strength and mobility, and their current level of fitness.
A comprehensive assessment of their status is taken during this evaluation, and used as the starting point in developing the plan of attack for their rehabilitation. We use objective testing through dynamometry to assess the above, as well as lay out clear goals and expected stages of care to achieve those goals .
Step 2: Structured Rehab Plan
This is where we get the work done. We split rehab into 4 stages - early, mid, late, and return to sport.
During the early stages of rehab, we work with our athletes more frequently - typically 2-3x/week. In these sessions, we aggressively work to regain range of motion and strength, but also layer in core and upper body strengthening. We routinely use technologies, such as Blood Flow Restriction cuffs, to allow our athletes to regain muscle and prevent atrophy more quickly. We will commonly have an athlete on an Assault Bike using only their upper body and non-involved limb to help them train their fitness, even while they are unable to use their injured limb on the bike. This is just one of the many ways we begin with the end in mind.
As we transition to the middle-stage of rehab, we're beginning to strength train much more aggressively. Here we begin to layer in complex movements, including deadlifts and squats, and work toward introductory plyometrics. These help us prepare for the bigger goals of our middle-stage - the return to running. We routinely test limb strength symmetry and begin to look at power output during this stage, to ensure that we only progress the athlete to running when they are ready.
As we enter the later-stage of rehab, we're in full blown plyometrics mode. Lots of jumping, landing, and cutting will be occurring here. It's also critical that we begin preparing the body for sprinting and the forces associated with it. This is when the athlete begins to feel most like themselves, and when they start to feel like the return to sport is really going to happen.
The return-to-sport phase is the most critical phase of all. Without it, all of the work we've done previously was in vain. We use objective benchmarks through a battery of tests, including: force plate testing, dynamometry testing, hop testing, and movement screening. These guide our decisions on when an athlete is ready to return to participation, allowing them to re-enter practice with their team. Throughout this period, we layer in reactive drills at the highest speeds to mimic the demands of their sport. We ensure adequate exposure to practice and drills before returning with limited minutes of true sport. Once they clear these hurdles, they are battle-tested and ready to make their full return to sport.
Our PT's and Strength & Conditioning coaches work together on these performance training programs and rehabilitation to ensure that our athletes are making steady progress through these stages. Our goal isn't just to safely return the athlete to their sport or activity, but rather to ensure that they gain the ability for long-term training and performance.
When Should You Seek Professional Help?
If you think you've sustained an ACL injury, then urgency is needed to get in front of a medical professional. They can help you to determine if the ACL was injured, along with any other structures in the knee (meniscus, MCL, LCL). Getting on the right path as quickly as possible will reduce the duration of rehab on the back end of any surgical intervention.
Critically important for return-to-sport is getting into rehabilitation before surgery - often referred to as 'prehab'. This ensures minimal muscle loss and atrophy, and assists in the early stages of recovery following surgery.
If you've gone through a surgery, getting in to see a PT within the first 10 days following rehab is critical. This is where devices such as BFR can be utilized to stave off atrophy of the muscles of the leg. It's also where range of motion training can begin, and reassurance can be given that things are moving ahead at planned pace.
If you're months out from an ACL surgery, and you don't feel like you're on track, or haven't felt that your rehabilitation is preparing you for a return to sport, then finding a performance rehabilitation facility ASAP is paramount. Far too often, athletes don't know they are behind in their recovery until they're 4-6 months in. The sooner you can find a performance rehab specialist, the sooner you can get back on track and find your safest path back toward sport.
Discovery Call With Our Team
We help athletes in Petaluma and Marin and Sonoma Counties return to sport stronger than before. As referenced above, we have developed our own ACL protocol for returning to sport. As such, it is very easy for us to help you understand whether or not you're on track in your rehab, or if you're at a facility that is capable of providing the objective testing needed to safely return you to sport.
Feeling discouraged is a natural part of the ACL injury cycle. The road to recovery is a long path, and can feel impossible when you don't have the right support on your team. Gaining clarity around how to make progress, especially as it relates to returning to sport, is critical for keeping your head in the game long enough to make sure you get back out there.
If you're feeling stuck, limited in your progress, or want to talk with experts who do this for a living, we suggest that you book a Discovery Call with our team - this is an opportunity to speak with one of our specialists free of charge. There is no pressure during these calls other than to understand if you're on track, and how you specifically can get back to sport in the safest and quickest manner possible.