All ACL Rehabs Are Not The Same

Go ahead and admit it, you really ARE impressed with Adrian Peterson.
Unless you make it your mission in life to ignore the NFL, you know that Peterson, running back for the Minnesota Vikings, tore his ACL and MCL on December 24, 2011. Surgery was December 30.
Eight months later, having not played a down in the preseason, he started the opening game of the 2012 season, rushed for 84 yards and two touchdowns. By week #16, he was the NFL’s leading rusher, averaging six yards per carry and had scored 11 touchdowns.
By the time the playoffs were over, Peterson had rushed for 2,097 yards, second most ever, was voted both the Comeback Player of the Year and the league MVP. And it all started eight months after the injury.
Enter Robert Griffin III, RGIII. We all saw that playoff ACL and felt for him as he tried to finish that playoff game. Same surgeon, rehab, roughly the same time post injury. Never took a snap during the preseason. Two league games in, Washington is struggling, really struggling.
Or how about Derrick Rose? Everyone[show_disconnected][show_to accesslevel=’Subscriber’] (according to the media) said he was ready, but he balked, preferring to forgo the whole season and wait for this fall. That’ll be around 16 months of recovery…..twice what Peterson took.
Two players, same injury (sort of), same surgeon, same rehab, about the same time post injury. And while the jury is still out on RGIII, he hasn’t had the same start that Peterson had.
When asked, I say in so many words, “Peterson is a freak of nature” and “No one should expect that kind of recovery” or other variations on those themes. Any player that suffers an ACL tear who looks at Peterson and starts to make plans about competing in 6-8 months is playing a difficult hand. In research, Peterson would be called a case study, or he might be considered an N of 1 study.
The real question is, how does the surgeon decide when a player is ready to play?
It’s usually better to work with results based on players of similar age, level of play, gender, etc. But here’s the deal. What’s important to the surgeon may not be what is of interest to the player. There are plenty of reports where clinic tests are less than ideal, but the patient says, “Great! I’m happy.”
In a survey of surgeons, the three most important issues were knee musculature strength, limb symmetry (by the 1-leg hop test), and the clinical examination (e.g., range of motion, swelling).
Some might say that the surgeons first concern is the surgical repair, and it should be. So, assuming these all say that the knee is ready, then why do re-injury reports cite rates of up to 24%?
Remember that the knee is but one link in a complex chain of events in movement. And because the knee is so for from the hip and ankle (meaning: exposed), chances are that a little goof in mechanics on either side of the knee could well be magnified at the knee.
A knee injury doesn’t happen in isolation. Unless the knee is struck directly, this weak link suffers the most. The strength may be fine, good range of motion, no swelling, and the knee can still fail. Or, all can be well, and the player just isn’t getting it done on the field.
Back to the stats. Less than 50% of athletes coming back from an ACL return to their pre-injury level of sports within 2-7 years. Read that again, with-in 2-7 years. Other reports indicate that only a little over 60% will return to their pre-injury level of play. Most surgeons will say that while a player might be able to start practicing sometime within a 6-9 month window after surgery, don’t expect to really feel ‘right’ for at least a year, if not longer (Derrick Rose should come to mind).
Now don’t be disappointed with surgeons. They are doing the best they can with the evidence at hand and their own experience with patient outcomes.
Published reasons behind recover problems include: (1) current rehab protocols may be inadequate, (2) current RTP criteria may be inadequate at picking up residual inadequacies, (3) rehab protocols may not be effective at returning the athlete to pre-injury levels of performance, or (4) any residual deficiencies can place either knee at risk of injury.
These all beg the question of how best to evaluate an injured player’s knee, of course, but more importantly is how does one evaluate the player’s ability to perform their sport.
Break it down a bit more, and how does