What have we learned regarding ACL Re-Injury?

Returning to sport after an ACL reconstruction can be a difficult road for many, especially if you had underestimated the commitment required for a successful return. I know the feeling.

Did You Know? …

91% of those heading in for an ACL reconstruction believe they will return to pre-injury level sport or physical activity. However the return rate is 83% in elite athletes, 55% in overall competitive sport, including amateur level sport, and only 40% make it back successfully to pre-injury levels of physical activity (i.e. the others had to downgrade or make significant modifications to their activity type, or level of competition). That’s only HALF!

The ACL graft itself matures at 22 months, meaning the peak strength of this graft is achieved at nearly 2 years. This coincides with a large drop in re-injury rates after 2 years.
Both physical readiness (your ability to perform physically), and psychological readiness (confidence, anxiety) are important to optimise.
The quality of your rehabilitation and its relevance to your goals is a HUGE one!

Some stats from the experts:

A recent study found the total risk of injuring either knee (graft rupture and opposite ACL combined) is 29% within first 24 months post ACLR, which is 6x higher than primary (first time) ACL injury. Of that 29%, 20% were contralateral (opposite) and 9% was a graft rupture.
Contralateral ACL ruptures are more likely in females, graft rupture is more likely in males
Contralateral ACL rupture is 2x higher than graft rupture.
In the first 12 months graft rupture rate is 15x higher than primary (first time) injury!
Between 12-24 months, it is 6x higher than primary injury
After 24 months it is still higher than primary injury, but it is unclear by how much. One study suggests it is still around 1 in 9 will still suffer an ACL injury.

For graft rupture, you are more at-risk if:

You return to sport too early!! Unfortunately 2 years is a big healing milestone that protects against re-rupture
You have poor knee stability when you return to training. We have clinical tests that accurately predict graft rupture risk at an accuracy of 90%!
You are younger than 21 yo
You are male
You had a LARS graft. Hamstring graft is the most common, and comes in second to LARS.
You are returning to sports involving pivoting prior to 2 years (linking in with the first point).

For contralateral ACL tear, you are more at-risk if:

You are younger than 21. There is a 15% elevated risk until age 40.
You return to sport too early. 9-12 months seems to be a critical time or “tipping point”
In my opinion, the real factor isn't just time, but what you are doing with it. If you are still compensating for the operated leg, injury is not a question of "if", but "when".

What Can You Do?

I can offer a few tips from my experience.

Age, gender, and graft type are all non-modifiable, meaning you CAN'T change them. So there is no point worrying about these. Focus on the variables you CAN modify – how long you can wait before returning to sport, your time and effort for rehab, your attitude and mindset, excellent knee (and hip) stability under stressful conditions at the end, and a structured return to sport are among the most important.
Complete your rehabilitation fully under the guidance of a qualified and experienced physiotherapist. If you are returning to sport, a sports physiotherapist may have more experience in this part of the rehabilitation. It’s hard. It’s long. But if you have had the reconstruction, you may as well do the rehab right.
Not re-injuring the graft is a tough one. Graft maturation is non-modifiable, yes, but it is a big fat issue we can't ignore. Several studies suggest the risk of re-injury will actually drop the most around 18-24 months post-op. That's 2 years! Some of us can't wait that long for various reasons, and that's when a quality rehab is key.
Realise it is common to “lose your way” a little and become bored, lose patience, and/or lose sight of the eventual goal, mainly due to the length of time it takes. If this is you, it is worth discussing these barriers with your physio, who can work with you and find a solution.
Please remember - completing each stage is not actually that easy. The above statistics for re-injury are collected from over 100,000 patients around the world, and they don't lie!

What can you expect from us at 20/20 Sports Physio?

Seamlessly integrate with your surgeon to ensure your rehabilitation is optimal for you
1-on-1 appointments at our clinic, and eventually in the gym, to help you with your rehabilitation from start to finish.
We are specialists in rehabilitation, and we place importance on exercise technique, loading programs, how hard to push yourself, and when to back off.
Strict watertight discharge criteria to make sure you are ready to return to physical activity and/or sport SAFELY. In my professional opinion that is really the key word here.