Episode 249 | The Sweet Spot Debate: Can You Return to Sport in Less than 9 Months in ACL Rehab?

What is up team? And welcome back to another episode on the ACL Athlete Podcast. If you’ve been following the news for the NFL at all. Packers tight end Tucker Kraft is just towards ACL, which means his season is sadly over. And if you follow these stories long enough, especially with professional sports, you’ll notice a pattern, even at the highest level with full-time medical teams, daily access to rehab. This is their job to rehab and all the best recovery tools possible.

These athletes typically take around nine months or longer to return to full competition. And that’s a really important perspective here for everyone listening to this, because if professional athletes with round-the-clock support are all taking that long, then I think it’s super important for 99.9% of us, the ones who are having to juggle work, school, family, or limited access to rehab care, to safely do it in less time. And people are always wanting to get back faster or accelerate this process. Today, I do want to touch on this article because this is how this came up, actually, I had an ACL article that just popped up because everything around my life revolves around ACL. The article was titled, “What’s a Typical Recovery Time for Tucker Kraft’s Torn ACL Injury.” This is by Packers news.com. Tom Silverstein is the journalist who wrote this article.

The thing that leads with is the Green Bay Packers generally don’t allow players back on the field for at least nine months from the time of their injury if the damage is a torn ACL ligament. It goes on to say that, basically, it holds true for Tucker Kraft, who tore his ACL on November 3rd, which was two days ago, as of the time of this recording, this is fresh. Giving y’all as fresh as possible. And then it just says that Kraft could be ready for the 2026 season if everything goes smoothly. 

And then it references three other ACL injuries to the Green Bay Packers in recent years. And the approximate nine-month timeframe was the same. Wide receiver Christian Watson towards the ACL on January 5th and was held at a training camp and practiced until October 6th. He didn’t start back until October 6th with his practicing. He practiced for three weeks before being activated for a game. Obviously, he was doing a lot leading up to that. It wasn’t like he just jumped straight into it. 

In defensive end, Rashan Gary tore his right ACL against Detroit, November 6, 2022. Returned nine months later, practicing for the first time on August 7th, and then center, Elton Jenkins tore his ACL in his left knee against Minnesota in 2021. He returned nine months later, practicing for the first time on August 14th. Slightly less than nine months after the injury, and these are just situations that I wanted to share in terms of this, because I think it helps set up the podcast episode itself. Because I want to dig into this nine-month timeframe and really what this looks like in terms of ACL rehab and the perception of it. 

I think that some things also push against this, which I want to talk about, which is one particular article from Heavy Hitters from Aspetar that I think is important to touch on. But I think it makes the case known that if we reference a lot of professional sports and athletes who tear their ACL, we are typically seeing that nine to 12-month timeframe. Yes, some are early. Yes, some put things on the line and get out there at six, seven months, but that’s their own risk. There are other things that go along with that they’re weighing that we obviously are not going to see, especially from the professional sports setting. We are not going to hear any of these details. They try to keep this close-knit. Players don’t want this stuff released. They have millions of dollars at play, their careers at play. 

And sometimes they don’t even disclose this stuff to teams themselves because they are trying to protect contracts. We have to understand context, the number of people who are involved, and there’s a lot that is riding on essentially these returns of these athletes. They want to get back, but we’re not going to always hear the details of it. But we will hear a lot about how long it takes people to get back. I feel like in recent years, I’ve appreciated that there’s been less of Adrian Peterson-type scenarios where this athlete got back in six months or four months. Yeah, it’s still consistently something that we hear. We’re hearing the narrative change a little bit better towards at least a nine-month and beyond process, for a lot of things. But there are still some stipulations around testing, which isn’t really done much. Great rehab is still a challenge, and access to good care is. But it’s just something that we typically see, and it’s nice to get away from some of those earlier timelines, if you will. And seeing more of the nine months. 

The thing that I do want to share is that in professional sports, that’s the gold standard that a lot of people uphold. If this pro athlete did this, then this is what I must do as well. If they have this particular coach or this type of equipment or this type of rehab, I should do that too. I will say there are a lot of good things in the pro setting. I think that sometimes it’s disguised as good. But I’ve met amazing clinicians who are not in the pro setting, and I’ve had very many clinicians that I’ve met who are not awesome, but they’re in the pro setting, so I’m just going to leave that there. Relationships and connections really help a lot with getting jobs. I think that it is just important, though. A lot of times, people will reference my surgeon as the pro team surgeon. If you want to lean into that, then I would say also let’s lean into what the pro athletes are doing in terms of timeline. It’s taking them at least nine months, with all things perfect in their daily calendar, resources, money, everything, a full-time job.

Now, let’s dive into this article because I think it’s super important to lay this out. I want to share the details of this article because it is new, and it is something that really pushes against this nine-month timeline. And for me, this is something that when it comes out and it’s something pushing against my bias, I’m like, whoa, wait. But at the same time, I fully agree. And these researchers are some of the best researchers in the world when it comes to ACL rehab, when they have dialed in their own process. And I think that’s why we also have to consider this article in context. This article is by Kotsifaki, who has done such amazing work. I have so much respect for her, and Aspetar and all the researchers and people who are doing amazing work there. But the article is in the British Journal of Sports Medicine and the title is “Nine Months the Sweet Spot for Male Athletes to Return To Sport after ACL Reconstruction.” I want to just talk about some details of this article because I think it’s helpful to break it down. 

When we look at their objectives, they were looking at how rehab adherence and completion impacted return to pivoting sports like soccer, basketball, handball, and whether returning before or after nine months post-surgery changed the risk of re-injury. And now, leading up to this point, there has been a lot of research that shows if you return less than nine months, your re-injury risk increases for ACL. And after nine months, it increases the probability of returning to sport and decreases the risk of re-injury, if we just took the collective data that is out there nine months and beyond. That’s why we also lean on that through this process, and you’ll probably hear anyone who’s in the ACL world probably use that number and probably say nine to 12 months, give or take.

The other piece that they’re looking at is the risk of re-injury if an athlete meets objective discharge criteria. What they looked at were 530 male athletes around the age of 27, was the average who participated in pivoting sports pre-injury. It included competitive recreational athletes, about 40% were pro or amateur competitive, and then it excluded female athletes. All ACL reconstructions were either done with hamstrings, patellar tendons, or quad grafts. And then when we look at the in-person pieces, they were at Aspetar under a very standardized, criteria-based progression system with basically mandatory testing every six weeks. This is a key player here. Aspetar has its process dialed in. They have tons of clinicians there, tons of testing resources. They’re a big research hub, and it’s amazing to get this data. But we also want to understand the setting that this is in. That’s going to be an important thing, is that if we have testing within a clinic at the gold standard, access to equipment, amazing six weeks, and they have their own process dialed in for their particular surgeons, graft types, etc. These athletes went through three rehab phases, essentially. You think about the early, intermediate, and advanced stages. You’ve got the early post-op stuff, you’ve got the intermediate, where you’re building more strength, and then you’re getting into more advanced, like pylometrics, reactive strength, like sports-specific stuff.

Progression wasn’t necessarily based on time; it was based more on objective test results. They had to meet strict discharge criteria to be cleared for sport. That meant pain-free testing, 90% strength in jump symmetry, completing a sport-specific progression, and being educated on prevention and maintenance. And then they were followed two years post-surgery to basically track their return rates and the re-injury. 

The key findings here the return-to-sport rates 72% of all athletes return to pivoting sports within two years. Those who finished rehab and met criteria were six times more likely to return to sport (return-to-sport rates by rehab completion). If you stopped early, you had a 50% chance of returning to sport, stop mid phase 70% chance of returning to sport, and then if you completed the full process with them, you had a 90% chance of returning to sport. Big key factor here. 

Rehab adherence was one of the strongest predictors of successful return. 

Timing. Less than nine months versus greater than nine months. This is key here. Among those who met discharge criteria, 71 athletes returned before nine months; 97 returned after nine months (key information there). No difference in new ACL or knee injury rates between the two groups, so that’s super key there. The average return time for competitive athletes was around 9.9 months, and recreational athletes took about 11.6 months. Now, what does this mean? Returning before nine months didn’t increase risk if the athlete passed all objective tests. But again, this is in a world-class setup with strict testing, full rehab adherence. Some contextual factors influence some of these athletes’ returning before nine months. The new injury rates were 9%, had new ACL injuries 5.7% on the same knee, and 3.4% on the other knee. Athletes who met discharge criteria had half the re-injury rates compared to older Aspetar data, which they showed, probably largely attributed to mandatory testing and how they monitor progress. These are some key players that I want to share. 

The last piece that I think is important is to emphasize the limitations and the context of this study. It’s a male-only study. Females were not represented, so we can’t necessarily generalize these results to female athletes. Different risk profiles, different return to sport timelines. It’s a single elite rehab setting, conducted at Aspetar, world-class, supervised in-person, very dialed in. The thing is, most ACLers do not have access to this level of care. And this is something that is super detailed, and then the testing is very dialed in. If you look at their process, it’s awesome. I love it. We even based some of our stuff on using Aspetar and their research. They’ve created so much research. They have the numbers to show these things, but we have to understand the context of it. High structure and compliance were big players. Had testing objectively every six weeks. The athletes had a lot of supervised sessions, so they had guidance through this process, again, with legitimate clinicians, through this process. It’s very different than most physio-based or PT-based, where you may go two to three times a week initially for insurance-based here in the States, and then it just ends up tapering down, typically. Of course, unless you have amazing benefits, unlimited PT visits, and you have good PT, then yeah, that’s awesome. But that’s far and few between, especially with where we’re at with healthcare and the amount of visits were allotted. 

The same thing also with other countries. We have athletes who see their PT once a month, every two weeks. We have ones that might go once a week. We’re trying to fill in the gaps here, especially depending on is the process is dialed in. I don’t think that, necessarily, the insurance model is fully the worst thing in the world. I think there’s a lot of bad things with it. But I think the challenge is one, as I’ve shared before, is that we just do not have consistent testing that is the gold standard yet, and physical therapists and settings are not equipped well enough with strength and conditioning and the ability to do very individualized approaches, or even having the facilities and the equipment to do so. The programs are very generic. And a lot of times, it’s guided by time-based protocols. And the exercises, to be honest, a lot of times, PTs will follow just what the surgeon has on a piece of paper.

Surgeons don’t train for exercise prescription or ACL rehab. They know how to do the surgery. And I don’t want to go on a tangent here. This is just the way it is. Sometimes, PTs, especially new grads, are thrown into it. We don’t get a lot of training on this, and then we’re like, okay, what’s the protocol say? We have at least a guide. But when the guide is not necessarily the best, and it’s been dated to, early 2000s or the 90s, and it’s been built by somebody who probably doesn’t understand exercise very well, they do know the surgery. It’s very challenging. It’s been this progression of this is what we’ve been doing. As we know, what we’ve been doing has not been working very well because re-injury rates are 1/3, 1/4 of athletes who go on to re-injure again. It’s not great. A 20%-30% chance of re-injury is not a great statistic. 

With that said, that’s where the model can be challenging. But if we have a dialed-in process and framework that is up-to-date with testing standards, I think we could get away with being able to give people a little bit more consistent things. Of course, individualized is needed, but with that said, that’s where its super key is, making sure this is up-to-date and meeting the athlete where they are. And we are testing well, equipment access is good, and we can monitor that more frequently. 

The other thing with this paper, there’s no randomization with this stuff. People weren’t just thrown into the early versus late returns, for example, to see how they did. It, again, excluded females, which I think is a big player here for this particular study, because we can’t necessarily extrapolate that to a pretty high injury-specific population. We know, especially for young female athletes, ACL risk is much higher; therefore, we can’t necessarily say they can return to sport before nine months because this was done on athletes in their 20s, males; therefore, it can make it a little more challenging. Even though we want to do that, we can’t do that because that’s just the way that we need to take data and make sure that we have very consistent proof of it to show us, like, okay, now we can basically approve this hypothesis, or we can disprove this hypothesis. And in reality, what research is doing is making things less wrong, versus this is the perfect, this is right. And this is the way we have to do it.

This study reinforces something we see all the time, that is not about a clock; it is about the criteria. Time matters for biological healing. How you progress, how you test, and how you prepare matter way more. Even at a world-class center like this, the average return was still somewhere around the nine-month timeframe. But some athletes did it earlier, but basically this showed that there was no difference in the re-injury risk on time return as long as they met the objective criteria. That’s the thing that I really want to stress here, that I think it’s important. The authors themselves said it best. Time is necessary, but not sufficient. So that just means that we can’t skip the process and expect the same results. Objective criteria, looking at movement, looking at strength testing, sport-specific work, jumping ability, putting numbers to it, should guide your return, not just using dates on a calendar, or I’m at nine months. And this is something that again, I want to share, was all in a control rehab system. They were part of a research study with mandatory testing, oversight, so that’s going to be very different than what we typically see in this space. And I think that this is just a huge thing to highlight here.

And the other thing that I want to share too, just from the nine-month perspective, it’s not just this magical, you get to the nine-month timeframe and you’re there. As I’ve observed this process, working with hundreds of people at this point, being able to work with and consult with different ACLers all over the world, our team has done this for so many people. When we look at this process, because of how much is just regressed down to be completely honest. When you have this injury, this knee goes downhill. When you have the surgery, the knee also gets dropped a little. This is something that we see, is we have to rebuild so much. We have to rebuild the quads. We have to get all the symptoms down. We have to get the range of motion restored. We have to get your capacity built up, your energy system, and conditioning. We need to get your power back up. We need to get your elasticity back up, your ability to move in space, your ability to get back to doing the thing, sports-specific stuff. There’s so much we have to work on from a physical ability standpoint, your preparedness for your sport, and to be just athletic in general. That is one thing. The thing is that it just takes a very long time. There are some people who beat this, and there are some people who are just genetically gifted. We all know people like that, so they might speed things along. And there’s some people who might have it a little bit easier than others for context reasons. The person who has the ACL surgery with a patellar tendon who has three kids who are under the age of five, and they are a teacher, is going to have a very different obstacle in front of them than the remote worker who has a patellar tendon graft who can throw their feet up and doesn’t have any kids and they have a girlfriend. It’s very different in terms of the context of how this recovery is going to go. 

And also, we can’t forget the biological healing. When we think about this process, everyone’s body responds differently to surgery. Surgery is not a normal thing for us, but it is something that we need just to the development of medicine. Therefore, the surgeries are beneficial to get these grafts back and fix things. The thing is the biology can do different things. Some people have swelling stick around longer, their pain response is worse, and then the complications of the injury or the surgery. Some people get DVDs more than others. There are so many characteristics that are involved with biology, and then we talk about healing. Some people lay down more scar tissue, some people just don’t have any swelling, some people end up having a harder time waking up their quads, some people have it wake up day one. And then some people have that scar tissue laid down, and then therefore it influences their range of motion, and then therefore they have to get it removed, versus ones who just have a smooth process. That’s biology. 

The other thing that’s a huge factor is the graft. Allografts are typically going to be faster. While we still want to give it the time and duration to ligamentize, with allografts, you’re going to feel better. You didn’t have a donor site taken. Guess what, you’re going to be feeling a little bit better than those who had a donor site and an autograft. And then hamstrings are typically going to feel a little bit better because their knee extensor mechanism, the thing from their quads all the way down to the patellar tendon and the tibial tuberosity, is not impacted. Therefore, they regain quad strength much faster than the patellar or quads. Patellar tendon is the next one that typically progresses a little bit faster than the quad graft, by nature of it, not directly influencing the quad as much as the quad graft does, and then we see the quad graft take the longest. I think that there will be research to support this. I may be coming back to correct this podcast episode one day, but I’m just going to put it out there that I think that the quad tendon is just going to show very significant deficits of quad strength for longer periods of time. We’re already seeing some of this, but we see these a lot. They’re growing in popularity a lot. Surgeons love them. It is a more challenging recovery to get your quads back. And I’m telling you we do the most dialed-in process. I have friends who see these who are incredible clinicians and coaches who also have hard times with quad grafts, and it’s just something that I think, by nature, for the direct influence of the quad and that tendon, it makes its own challenges. It will take longer. Therefore, when we look at this from the nine-to-12-month perspective, all these people are going to progress at different rates based on all these factors. But I do think that biology plays a huge role, the physical preparedness of this process, that we need nine months to do that. You need nine months to ligamentize that and make sure that the ACL turns into an actual ligament. 

I think those are factors that are so key in this. While this paper does show, it can happen sooner and I think that most athletes still need more time to develop these qualities, especially outside of the small percentage of people who might get there faster. When we’re getting to this and looking at this, at the end of the day, the question shouldn’t be when can I return? But most importantly, and this is what Kotsifaki stresses, is not when, but how am I returning? I think that’s the thing that we need to stress. Time gives us that framework. It just gives us a proxy of what we need to accomplish. And I think that’s why nine months is so helpful compared to six. It’s just more time, and therefore, it allows for more time to develop these things. Let that knee and that body heal more, so the ligament to become a ligament. But ultimately, objective criteria are what protect your knee and set you up for long-term success. And this research study supports it. 

I do think that just anecdotally, I’ve had people come back before nine months, like we might communicate about what that looks like from the research and the risk of that. But they have hit the criteria. They have something on the line, and guess what? We’re going to make it happen as long as they know the risk reward of it. We’ve talked to all stakeholders involved. They understand that. That’s a very key component of this process. Whether you’re someone who’s nine months out, you’re 15 months out, you’re seven months out, focus less on the number of that month, if you will, and more on that green light through strength testing, making sure your power, your range of motion, your knee symptoms, the sport-specific progressions are all the things that we want to look at, but measure them very objectively. That’s going to be super key here. I just wanted to share: one, we are pro athletes who are taking this long. Two, is that there’s a paper that shows and pushes against the nine-month sweet spot timeline. But you’ll still see, when you look at the details of this paper, that nine months is still a very common thing, if not more than that. I want to normalize this for some people who think maybe that they can beat this, or that they think that it’s something that we just tell people, or maybe we need new research. It really does showcase that objective testing is going to be so key. I think it’s the most important thing in this process, along with just an individualized approach, to be able to make sure that we reduce the risk of re-injury. And that’s going to be what’s so key. We’re trying to reduce how many ACL injuries happen, and it’s just something that I think until we get better testing, better education around this process of how to rehab them. Then, being able to make sure that we can individualize things for athletes and see them through this. That’s a system-based issue that I think we will be able to see ACL start to turn around. I think also if we can get away from sports specialization too early in the process, that I think the ages from 12 to 18, we will see fewer ACL injuries, personally. That’s my own personal recommendation, my own opinion here.

But the ability to have athletes strength train more, develop themselves in a variety of ways, versus playing one single sport every day, all year round for club sports and school sports, will be a massive game changer to help this as well. But if we’re talking about someone who’s injured it and we’re trying to prevent the next injury, testing, very good, individualized programmin,g and being able to have expert guidance is going to be the thing that prevents that second ACL injury better than anything. I will stand by that. 

I hope that this was helpful. I wanted to break this down. I feel like this nine-month sweet spot is something that’s talked about a lot. But I also wanted to reference: what are the elites of the elite doing? And if you look at other sports, they’re doing the same thing for the most part. If they come in earlier than that, they probably have something on the line for that. The Olympics happen. And I read a story about an athlete who basically went through it as quickly as she could so she could do the Olympic event.

Now it’s an Olympic event. It happens every four years. Also, you’re not sure if you’re going to make it because four years is a very big turnover in an athlete timeframe, especially if you’re on the older side of being an athlete. And I’m talking about you’re in your early 20s, it’s not like we see a ton of people in their 30s competing in the Olympics. So that’s something that’s at stake.

I hope that this shares some perspective for you guys. I will link some of this info in the show notes and if you have any feedback, or if you have any thoughts on this, I would love to hear this. You can send me an Instagram message, you can send me an email, whatever that may be. But I hope that you guys have a good rest of your day, night, morning. I feel like with daylight savings time, it always feels like night now. But we’ll catch you next time on the podcast. This is your host, Ravi Patel, signing off.