Episode 104 | ACL Rehab Considerations for the Older Athlete

What is up team, and welcome back to another episode on the ACL Athlete Podcast. Today is episode number 104. We are talking about ACL rehab considerations for older athletes. I wanted to tackle this topic this week after I got a question from an ACLer. He’s 53, very athletic. He’s got an ACL tear and considering options for surgery. And basically, it was just asking, are there things that I need to worry about as an older athlete with an ACL tear? And just considering this whole process- which I thought is a really good question. And while my answer was mainly that it doesn’t really matter about age. And if you take away anything from this podcast, it really doesn’t matter that much. But there are some factors to consider and for us at the ACL Athlete, age is truly irrelevant in a lot of these decisions we guide you on. 

We don’t really care much about the age. You can check out past podcast episodes on how we define athletes, how we work with age, and just our philosophy in general. Our approach is different than probably most. Ours is more focused on your specific context rather than generalizations of being a certain age. Because there are plenty of people who I know who are 15, 25 who are sedentary, who tear their ACLs in a weird accident. And then there’s people who are in their 40s, 50s, and 60s, who tear their ACL doing something crazy like picking up soccer, alpine skiing, or all these other different ways. So really the context is very specific for that person. But today, I want to make sure that we tackle this for our older athletes. If you’re listening, this is for you to consider as you are trying to decide on ACL surgery, graft options, and just different things along the journey.

And some of you might be listening, you’re like, I thought this only really happens to younger athletes. Well, while most sports news and even research you see around ACL injuries and surgery is focused on younger athletes, typically somewhere around the ages as young as 14 to their 30s. That’s the range that you’ll typically see where most research is. But once you get into the 40s, there isn’t as much research, there isn’t as much more expansion on surgical approaches or treatment approaches. And what’s interesting is that there’s a lot of athletes in this category or in this range, if you will, who do tear their ACLs doing some sort of activity or sport. And then they have to consider the same exact route as younger athletes playing organized sports or recreational sports or just doing it from just general play. 

And just for the purpose of this episode, we’re going to establish older athletes because there are papers that will allude to it, or if you talk to different medical offices, surgical approaches, usually the age of 40 and above is dictated as an older athlete. Just as a caveat here, we have a lot of 40 and 50-year-old ACLers we work with, that can literally crush me in certain things like sprinting, endurance running or cutting, or playing certain sports or activities. By no means am I sitting here being like, you know what? These older athletes are different person and they need different treatment. I am here to respect them because a lot of them can kick my butt. Let’s dive a little deeper here into the older athlete considerations for ACL rehab surgery and more. To start this off, to me context is really important. 

With any surgical intervention, with any injury, honestly, with any patient encounter, context is important. There’s a subjective report where we ask you questions to help tell a story. And then there’s the clinical side where we might do some testing or some objective testing, there might be some imaging that needs to be done. But all of this information tells a story to help give the 360 about what we need to do for your specific case. We need to get to know you as a person, your history, your goals, and so on. And some of the major decisions that I want you to think about in this process, two of them that we’re most importantly going to talk about surgery or no surgery and graft type. 

Surgery or no surgery? That is usually the big question that is asked in ACL rehab, in the ACL injury itself. And as you probably explore a little bit more, you’re starting to see more people who maybe go a non-operative approach, or maybe they’re hoping that the ACL heals. There’s more research that comes out to help support some of that. But again, it’s still in this infancy, we don’t know the quality of that, we don’t know the functionality of it. But it is a question to ask. It’s not just something where, okay, the ACL tears, we’re going to rush to surgery. How do we answer this question of surgery versus no surgery for the older athlete? Well, the best way to kind of think of it, and I think that this is a very helpful framework, is to think about the rule of thirds that has been used for quite some time in this. 

You can think about this as your three groups: you got your copers, you got your adapters, and you got your non-copers. Copers are basically able to have their ACL tear and then they’re able to resume all the previous activity without any issues for at least one year after the injury. It might be the knee has adapted well to it. You don’t have any functional instability. It could be related to just the activities that you do that don’t really stress the ACL in general. Maybe you’re a runner who just does straight-line running, then you might be able to get away with it. But if you are maybe a soccer player or someone who has cutting and pivoting in your sport, you might be one of those people where the coper might be a little harder because the ACL is more in demand in those activities. 

Then, you have adapters, so modifying or reducing activity after you have the ACL injury. You might be someone who’s like, I tore my ACL playing pickup soccer. I’m not going to play anymore. I’m only going to go to the gym. Maybe I’ll just run a little bit. And that makes you happy. You could be an adapter and that’s something that is not a big deal to you. And so then the third one is non-copers. These are the people who have ACL tears and they can’t really get through their everyday tasks, or maybe it’s the activities they want to do and they still feel like their knee is giving out or having issues. And they’re the ones who typically go on to have ACL reconstructive surgery. You have those three groups to consider for surgery or no surgery. Now, I wish this podcast could answer whether you should or should not have surgery. But we can’t answer that today because of the scope of the episode, as well as your specific case. But these are just like your things to think about if you are to consider surgery.

And then one of the other things that I want to tackle is this myth of osteoarthritis. With ACL rehab, with the injury itself, there’s this notion that if you do not have surgery, you’re more likely to get osteoarthritis because you don’t have the graft there. That is not true and has been proven by research and with evidence that it’s pretty much similar outcomes. Whether you tear your ACL and you have reconstructive surgery or you don’t have reconstructive surgery, the osteoarthritis risk is pretty much the same with anyone who tears their ACL. And this is just something that is fairly true for anyone in this process. You have an increased risk of osteoarthritis. It’s just an injury to the knee. The knee joint itself has changed. There are people who go on to have great knee joints for a long time. There are other people who end up having OA a lot earlier. Usually, a meniscectomy or something to the meniscus itself where you cut it away, and that meniscectomy increases your risk. But in terms of the surgery or no surgery for the ACL, the myth of that OA is not true. And that’s one of the things to just consider if that’s making you feel forced to have the surgery. 

The other consideration is your graft type. This is the other big thing that we hear with ACL surgery and with older athletes especially. I’ll have conversations with the athletes all the time where they’re like, which graft type should I use? I’m over 40. My surgeon said I should use an allograft. And if you look at the research, it’s actually pretty similar across the board, whether you’re going allograft or autograft, failure rates are pretty similar. It just comes back more so to your specific goals, and also whether you want to go down the path of an autograft or an allograft. That’s one of the things that need to be discussed based on your goals, your history, and also kind of what you want out of this and what your surgeon does really well. Those are the things that you really want to consider, but just know that there’s no significant differences that exist in outcomes with the grafts, whether it’s autografts versus allografts.

You’ll typically see the allografts because it’s just one of those things where it’s less trauma to the body itself. And it’s something where people who are older are usually people who are less likely to go to higher-level competition sports. And that’s a big reason why a lot of surgeons go that path because you have more time to heal, less likely to put as much strain on the ACL. And there might be other considerations. But as far as graft type usually, most people are like, this surgeon told me I had to get an allograft. But just know you have options and make sure to explore those options as best as you can. 

Bone quality is another factor that I want to talk about. It’s something that you want to make sure you have good bone mineral density, and that could be established via a DEXA scan or other types of testing. But you want to know that you have good bone where those fixations are so that the graft can be fixated strong and can heal into that bone. Something important to consider here especially is osteoporosis which is common in older female athletes. It’s just something that you need to consider just to make sure that the bone is healthy, you get the bone marrow density that could be fixated and it’s just something that could possibly be overlooked. And so that would be an additional factor to think about with this ACL rehab, with this surgery, having surgery or not. So that is one that you can think about and get tested if needed. 

And then the last thing, which we touched on a little bit about the myth of OA if you get surgery or not. I actually want to talk about osteoarthritis or OA as a factor in terms of decisions. With older athletes, there is something where mild or moderate osteoarthritis could already be present. It’s a natural process in the human body to some degree. Sure, if there’s like old trauma or maybe someone has higher inflammatory markers or a genetic condition to it. There are a lot of factors that play into osteoarthritis. Now, if you look at the research that has been established, if there’s mild to moderate osteoarthritis, or maybe it’s in just one part of the compartment, then it could be something where you don’t necessarily have to opt out of ACL reconstructive surgery. It’s just a factor to consider. But it’s one of those things where even in some research studies, they showed improvements in knee stability and function. OA might have developed a little bit later or come back, but it’s one of those things that isn’t off the board just because you have existing osteoarthritis. And it’s a higher likelihood if you’re an older athlete, you’ve been on this earth longer. There are things that can happen internally to our bodies, just like wrinkles on the skin to consider whenever you are getting imaging or whenever you are going to look at having surgery.

Now, one of the things I wanted to bring up is research. There is not a lot of research on older athletes in ACLs. There’s some but not a lot. And so one of the ones that I did want to bring up is the anterior cruciate ligament injuries in the older athlete by Best, et al in 2020, about a couple of years ago. It talks through the process of an older athlete and some of the factors to potentially consider with this process. This paper found that non-operative treatment with some activity modifications and physical therapy can be an appropriate option for non-athletes who are older than 40 years of age with physically low-demand lifestyles. So that is just one factor to consider. You might have a very low physically active lifestyle just in general, and you might be listening to this and you’re like, all right, well, can I do the non-operative treatment? Well, they adjusted their activity. They did physical therapy. And it could be specific for a certain portion of this demographic who fits these specific criteria.

And then results also show that for the people who are basically unresponsive to non-operative approaches or athletes who want more physically demanding activities, ACL reconstruction can actually be helpful and can help people return to sports and to good function and activity with a stable knee. One of the things that it highlights is that you just have to evaluate the person as a candidate for surgery based on different variables of timing, graft choice, and postoperative rehab and not just something based on age, which I did appreciate about this specific research article. 

In conclusion, it said outcomes of ACL reconstruction in older athletes are similar to those of younger patients. To date, published evidence is inadequate which we had mentioned to determine the long-term effects of non-operative and operative treatment, as well as the role of ACL reconstruction in the development of osteoarthritis in the older athlete. Basically, there’s not enough evidence to show whether the long-term effects are good or bad for the non-operative versus operative in this specific population, as well as the development of osteoarthritis. So that’s playing to that whole, like, we need more data, we need more evidence, we need more research on this. But overall, this paper does show that you’re not in a bad spot if you do want to opt for it. Instead of surgeons pushing people to not have the surgery or to just stick with an allograft. This one actually highlights ah, well, if you do go with an autograft as well, the outcomes can be fairly similar.

Now, I want to talk about some unique challenges. Some of the things that I think don’t get necessarily highlighted in current conversations with surgical consults, are just some of the things for the older athlete if you’re listening to consider. One of the things you’re going to have to do in this process is get imaging. I had mentioned earlier how imaging. There are sometimes where you’re going to find stuff on imaging, where it’s going to seem very negative. And especially the older you are, the more we know with research that there’s likely to be “wrong” on the imaging. We see this with low back pain. As people get into their 70s, 80s, and 90s, people have significantly bad, if you will, MRI readings. But a lot of them are asymptomatic; don’t have any issues. It’s just a natural progression of them getting older and the wear and tear on your body. And so that’s one of the things, if you are an older athlete to consider, your MRI might look a little different than the 15-year-old ACLer who just tore his ACL.

So that is just something to consider with imaging, that it’ll be just like wrinkles on the skin. As you get older, your wrinkles don’t hurt, but there is a natural progression of getting older. And there’s likely more of that stuff with imaging and on radiologist reports. This is where meniscus tears or osteoarthritis. All these things that I’ve seen with athletes and imaging, and they get these radiologist reports or they meet with surgeons and they’re like, oh man, this knee shot. The worst knee I’ve ever seen in years. They’re able to run. They’re able to jump, they’re able to do all these things, which is just kind of crazy. They’re just basing this patient solely on an image. 

This is one thing that I just want you to be mindful of, and to just see that it needs to match up to your findings with your subjective exam, which is what you are basically telling the story of and what you feel and the clinical exam. Testing out the actual knee, seeing its functionality, and making sure that that stuff coincides with the imaging that you have.

Another factor I want you to consider is joint integrity and your injury history. Maybe you are someone who has a retear and you’re in your 40s, 50s, maybe 60s, who knows? And so that’s going to factor into the choice of having surgery, the joint integrity itself. We just want to make sure that’s in a good place if you do decide to have surgery and decide to make sure it’s a good environment for that knee to functionally be set up for success.

The other thing here is also the history of tendinopathies. A lot of times people will go and get grafts and maybe sometimes they’ll get an autograft. Let’s say, for example, you’ve had a history of patellar tendonitis, on and off, for years. And maybe you are trying to get an autograft. The surgeon likes to do a patellar tendon autograft. This is something that’s important, and it’s something that maybe they’re pulling from a place that has already been broken down because of the history of tendonitis and tendinopathies. Then maybe it’s something to decide, well, do we pull from a different area or do we shift to an allograft? Because maybe some of those areas have been broken down and that could be analyzed based on some imaging to see, all right, is this going to be a good graft site? This is especially important for autografts and it’s something that can get missed quite often if you’re an older athlete or if you’re an athlete that has dealt with a history of tendon-based issues and you’re trying to use that tendon to potentially be your new ACL. You want that thing to be as solid as possible, and you want to make sure that thing heals and has the capabilities to do what you want.

Another factor here is going to be healing potential. We know that the body doesn’t heal and recover quite like someone who’s going through it in their teenage growth years. We know that. I feel like for me personally, once I hit the age of 22 or 25 my body changed and it was no longer being able to bounce back in the next day or something. It takes a second to recover, whether it’s sleep or drinking too much, or whether it’s training too much. All these things, as we get older, it’s not as easy to just bounce out of it like we did when we were younger. I think this is something to consider for your own life. Are you a good healer? Do you notice that maybe it takes a lot longer for things to improve in your body and you just want to make sure that you aren’t sending yourself out for a longer process than you need to? Or, it helps to potentially frame that you know it might take a bit longer. Just something to factor in is your healing potential and what that might look like with another ACL surgery or an injury and seeing what that path will be.

And then lastly, on this point, goals. Are you in pursuit of the same goals that really demand the need for the ACL? Are you someone who’s trying to get back to pick-up soccer, to be able to play pick-up basketball? Is it something that is going to be cutting and pivoting that is going to really demand your ACL? Maybe it’s skiing or snowboarding, maybe it is hiking and it’s rock climbing and bouldering where the demand on it is going to be a bit more than just maybe going for a two or three-mile run. Or, are you someone who wants to modify your activity and be in this category of less risk of re-injury? 

And in a realistic nature, whenever people get past these really highly competitive sports, this is where people end up sitting. And when you see people who end up doing well as copers, the question becomes, do they cope well because their knee is stable and they’re getting back to those higher level activities they once were doing? Or, is it more of coping because they have adjusted their activity level to fit basically what it is for their knee and basically not risk it or stress it nearly as much as what the activity that tore it first did?

This is what we typically see, honestly, regardless of age as well. Even younger athletes may stop playing the sport and therefore their knees are able to withstand the life stressors that they have because they’re doing less of that thing that really did stress their knee or put it in more vulnerable positions. But this whole activity modification is also a byproduct of being an adult. That’s one thing that I want to make sure we bring up. As an adult, you don’t have those competitive things going on as much. You’re able to adjust your lifestyle and prioritize the things that are more important versus not. And it’s just a little different than the high school athlete or college athlete because life priorities are different. This is just something to think about related to your goals. If your goals are to get back to something that you truly love, that is going to demand your ACL, I say go for it. 

And then worst case, like you’re going to have to adjust the activity level. But it’s important to come from the place of your goals and what makes you happy and go from there versus just completely settling to being like, you know what, I’m not going to do any of this. And just being fearful almost of what activity you choose to do. 

And to round out this episode, I wanted to talk just about real life. And this goes back to the same point I just made about your goals, it’s the trade-off, essentially. What’s going to serve your mental health and overall physical fitness? And you have to weigh the risk-reward of this and also just live your life to some degree. I know that’s pretty cliche, but it’s true though. I see so many people who truly get paralyzed by this. They’re so stuck. They stop being active. Of course, that impacts their mental health. And some of you might be listening to this, going through this right now. And the thing is, is that you’ve had probably some things taken away that gave you a lot of joy and a lot of happiness.

One of the things that I suggest, if you’re considering surgery, non-surgery, rehab, or any of these factors to make a better choice, start from what is that’s most important to you. And trying to decide, okay, what is this path going to best look like? And what I will say here is that I would rather you go through with the surgery and push hard for that next year. If that means having better mental health and being healthier overall. Then you opt out of surgery and try to just force that and that serves your mental health negatively and not doing the things you love or being fearful. Those are the things to think of the big picture and then be more specific on the action plan. And guess what, this isn’t a rush in the process. Most of you do not have something where that is time-sensitive. And so that way you can always test it out and see, well, let me see the non-operative if you want to try it for three months. And if it doesn’t work out or your knee isn’t handling it, guess what, you can have surgery. You just consider a lot of these factors to make the best choice about the type of surgery you want to have. And that’s what’s going to be most important here. How can we work back from your goals, and your specific contacts? And being able to make sure that you essentially get towards those things with the right plan in place, whether that surgery or not, the right graft choice. Anything that’s more specific to your specific case. 

And the other thing that I will say going along with time is taking longer than you need to do your rehab really well. Get really strong. Don’t rush. The longevity in the focus will pay off dividends in the long run. Don’t try to force yourself back in four months or six months. It’s something that if you put in the work, really push hard, and have a good plan and guidance, you’ll be really set up to have the best outcomes, no matter the age. And that’s one thing I want to stress today is that, really a lot of the things that I talked about really didn’t matter a ton about age. Sure, there are some pieces like, okay, your activity level, priorities, potentially like some of the more anatomy and function base, like osteoarthritis, tendinopathies. There are those things. But a lot of these things are things that we factor in no matter the age of the athlete. And if you’re sitting here listening to this and you’re 20, 25, 30, regardless of the age, these types of things are still things to consider and can be helpful in terms of making the best decision and considering the best options for your ACL surgery, rehab, and just the course of your life to get back to the things you love to do.

I hope that this was helpful, team. I wanted to make sure that this was a resource that was out there for anyone considering this. And if you have any questions specific to this, or any feedback, always open and welcome to it. Send us an email at ravi@theaclathlete.com. Hit me up on Instagram @ravipatel.dpt. And before I sign off, I have two things for you. One, leave us a five-star review; whether you’re on Spotify or Apple Podcast, please do that for us. Helps us out a ton, and helps us to reach more ACLers. And the messages we get every week, I read them, respond to them. Thank you all so much. Go and do that for me. Number two, we are about to pump a lot of value through our newsletter. Make sure you sign up for that. Get on the list and we will be sending a lot of really cool stuff that is going to be exclusive to our readers and to our newsletter subscribers. If you’re not added to that, then go to the show notes. You can add yourself to the newsletter and sign up. You can also go to the website at the bottom and sign up at the website. 

All right, team, that’s going to do it for today. Thank you all so much for listening. This is your host, Ravi Patel, signing off.