Why 9 months?
Considering when to return to sport after ACLR (ACL reconstruction) is a hotly debated topic.
Consider Bob, who you haven't seen on the soccer pitch for six months. He tore his ACL, but feels great now after surgery. He's been running for two months, has no pain, and felt like he now was the time to rejoin the soccer league. But if you follow professional soccer, you might know that Zlatan Ibrahimovic, a professional soccer player, had ACLR surgery in May 2022 while with AC Milan, and his first game back was in February 2023, a full nine months later. If a professional soccer player needed nine months before playing sport, why does the recreational player return sooner?
The culprit is a lack of education and structure. Here's why:
Plenty of studies have confirmed that when a tendon graft is used in place of the original ACL, it goes through a transformation process. It was a tendon before, and must become a ligament after healing (ACL stands for anterior cruciate ligament, after all). That process, referred to as ligamentization, takes time. As this graph demonstrates, only around the nine month mark does the graft become about as strong as the original ACL.
Coupled with evidence from multiple papers that state how the risk of tearing the new ACL is much higher if return-to-sport isn’t delayed till nine months post-op, it's obvious why most athletes should delay their return to sport. 1
But if the evidence is so abundant, what's missing from the recreational athlete's rehab process? Well, for starters, if you let the current healthcare system manage your care, you'll find yourself in an insurance-based clinic that can only make your rehab last about three to four months. After that, good luck finding cost-effective care for the rest of your rehab.
Then there's the lack of education during rehab. If individuals knew how risky return to sport was due to the healing their new ACL still required, why would they? More often than not, nobody tells them. They are dropped off after four months of rehab, some amount of running ability, and believe that because they can run, they have what it takes to participate in their sport. Everyone knows a Bob, especially a Bob that tore two or three ACL’s.
To top it off, if a recreational athlete is lucky enough to know they should wait, they are left wondering what else they should be doing. "Get stronger," might be the total sum of the advice he or she is given. Questions like “How much stronger? Where? How does one do that? Do I do the same exercises I was doing in physical therapy?” are bound to aris. Going from where they are now to where they need to be is no small feat, and requires structure recreational athletes are often not provided.
Fortunately, the ACL Virtual Assistant, or AVA, covers that. AVA takes a no-nonsense approach to rehab, and ensures you've cleared the ninth month marker before returning to sport. There are so many more goals that need to be cleared before the nine month hurdle, but should an athlete clear them earlier, nine months is still the gold standard for return-to-sport. AVA provides the structure and education most athletes never get during their rehab, so going from where you are to where you need to be isn't a game of snakes and ladders.
If you are lost in your ACLR journey, pick-up AVA in the app store. And remember, there's a lot that goes into deciding when an athlete returns to sport. But at the very least, wait nine months!
1. Beischer S, Gustavsson L, Senorski EH, Karlsson J, Thomeé C, Samuelsson K, Thomeé R. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther. 2020 Feb;50(2):83-90. doi: 10.2519/jospt.2020.9071. Erratum in: J Orthop Sports Phys Ther. 2020 Jul;50(7):411. PMID: 32005095.
