In this episode, we discuss the 9-month time frame in the ACL space, why it is known as the cutoff for minimizing risk for re-injury and the potential problems that could arise with this framework.
What is up guys, and welcome back to another episode on the ACL Athlete Podcast. Today is episode 121: Is 9 Months Good Enough for ACL Rehab? This is going to be an interesting topic that I want to really cover today because of a message I received recently. And I think this whole notion of nine months, it’s a cutoff that you often hear in ACL rehab, especially if you are online and you’re reading through things and you’re following people who might post a little bit more about ACL rehab. And especially physical therapists who specialize in this, are touting the nine-month timeline, which all has good intentions. But I want to highlight a little bit about the why behind this and this message that I got and where are some ACLers they can get into this mindset of, oh, I’m at nine months or post nine months, so I should be good to go because that’s what people say.
I want to start this by reading the message that I got from the ACLer reaching out. And this is something that he had mentioned initially, that a certain amount of time has passed. He had been touting time as the big reason why he was ready to start playing basketball again. And for context, that’s what he’s asking to get back to playing basketball. And so the message goes. I mentioned time because I know studies say nine months is the minimum time, regardless of the rehab process, and the chance of re-injury decreases every month. That passes all the way until the one-year mark. I am now 11 months post-op, which I initially thought stacked the odds in my favor. This is something that’s really interesting and it’s not uncommon for people to reach out and say, well, I’m past this point, so I should be okay and good to go. I’ve done probably enough of the rehab, but time has passed.
Even these research studies say like, that the more time you delay, the better off you are—which is great. But the thing is, is that we’re missing some pieces that are so crucial to this that I want to make sure that we highlight in this episode today. The nine-month cutoff is what you will see by most people. It’s the thing that I reference a lot even in other podcasts. And just people who are familiar with this ACL rehab process, whether it’s clinicians, coaches, surgeons, or maybe it’s even on the ACLer side of where you’ve done your own research and you’re like, wow, that nine-month cutoff does seem to be the sweet spot of the minimum to make sure my re-injury risk is decreased.
And that’s the thing we’re trying to make sure, not only that you can get back to the things you love doing. But that you don’t go back and tear your ACL again. We know that re-injury rates are super high in this space, ranging from 20% to 30%, which is just way too high, especially for an injury and a recovery like this. And where this nine-month cutoff comes from is from a lot of different studies that have shown an improvement in that re-injury risk, reduced risk of re-injury. But one of the ones that commonly comes out and is actually the one that this guy is touting is for every month that return to sport is delayed until nine months after ACLR. The rate of knee re-injury is reduced by 51%. And that’s a Grindem study in 2016–great study, awesome study.
Here’s what a study like this provides correlations based on statistics and so that’s great. And I referenced this study a ton in terms of working with ACLers. But you got to look through the details of what is important with that nine-month process and what they see lines up that also correlates. That gives us a good idea of, okay, this might be the reason why that re-injury reduces by 51% each month up until a nine-month process. And usually what we do is I’ll tell athletes, I give them a 9 to 12-month window. If you’re one of my ACLers on our team, you hear that 9 to 12-month window all the time.
And if you are going through this process or you’re working with someone in this process, this is actually what you should be telling people as well. Is that a 9 to 12-month window where you will see that to normalize? And then, of course, give or take. There are people who are all along this bell curve if you will. There are people who go back a little bit earlier and there are certain goals or time-sensitivity standpoints where you can do that. Of course, you’re accepting risk with that. And then there’s plenty of people who end up going past the 12-month mark. We’ve got ACLers in that place right now. And there are people who are going to fall into that bucket of past the 12 months because of a number of things that happen with ACL rehab. You guys all know this. And so what I want to make sure we tackle today is people see that nine-month mark. And I think that overall message can get lost, whether it’s from social media or just people talking between each other. I want to really make sure we address why this nine-month mark can be valuable and where it could also potentially get us into trouble if we rely too much on it.
The thing that I want to make sure of is that when people think about this nine-month mark, even in this example of this athlete reaching out to us. People think sometimes that with time passing for some reason, that is going to magically improve their re-injury risk. And that doing very minimal, they could still potentially get by or whatever that minimal could be, or just enough in order to get to that threshold and get them to a place of maybe they’re good enough to be able to go back to the sport and have a reduced risk of injury, and at leading into that nine-month mark, maybe. But let me talk about what those nine months give you, and that’s the most important thing here.
To me that nine-month window gives you two things after an ACL reconstruction. One, it allows the graft to heal and to go through that ligamentization process. We see this potentially continuing up to two years after you get the ACL reconstruction. There’s research that has shown this. And with nine months, it looks like it’s a pretty good threshold for that graft integrity to go from that tendon that was taken if it was an autograft or even an allograft. The ligamentization process takes a long time. And what we see is that we start getting into a good threshold after the nine-month period. And it allows that body to basically take that tendon initially to break it down and then to be able to make it into that ACL ligament that we want it to be after that ACL reconstruction. Nine months gives us time to do that.
Then, we’re talking about number two, which is so important. It’s developing the physical qualities we need to get back to the sport, the activity, or the movement that we want to get back to. And qualities are the foundational components to athletic movement or movement in general, range of motion, mobility, you’ve got work capacity where you could do things over a long period of time. Think about having a really solid gas tank. And then we have strength, force output, power, and reactive strength to do those things fast, elastic, to make sure that you can do that very bouncy and forcefully. Basically, trying to use your muscles, your tendons, and the joints in your body to store and release energy very quickly. And so these are all pieces of qualities that we’re trying to develop. To think about this a bit more simply, think about just the force that you generate or that strength, using it fast, being able to run, jump, accelerate, decelerate, change direction and sprint if needed for your particular sport or activity. And then making sure that we could do that in a reactive nature to make sure that we can do that with a game going on or multiple pieces moving. Or maybe you’re on the slopes and you’re trying to make sure that you’re looking out for the different terrain, and there’s also people around you.
There are so many different ways that these different qualities need to be developed. And this nine-month timeframe actually gives you so much time to be able to work on these things. And it’s almost like the needed time to be able to do that. And I think the other thing that doesn’t get talked about a lot is how much deconditioning that can happen after this injury and after this surgery that doesn’t necessarily get addressed. And it’s just what the body does after something like this, it shuts down, and the quad shuts down. There’s a lot of things that we’re still trying to figure out about ACL injuries, not only locally at the knee joint or the quads, but now we’re starting to learn so much more about spinal cord reflexes, inhibition, descending motor cortex. The brain now having changes with different ACL injuries. There’s a lot of complexity to this injury. It’s not just a straightforward, your knees hurt, let’s have surgery, let’s get it recovered, and move on. There’s a lot of complexity.
And so with that said, there is a level of deconditioning that just naturally happens. It’s hard to continue to maintain some of these attributes or these qualities unless you’re able to continue to train them and you have the best environment, support, and program, if you will, to be able to do that. As soon as we get athletes in, our goal is to try and make sure that we don’t let their deconditioning drop. We want to make sure we keep the unaffected side as strong as possible, and keep those qualities up as much as we can without doing any detriment. Trying to make sure we train up the ACL side with some prehab. And then also keeping the upper body and core and things like that moving. But at the end of the day, that athlete will still decondition to some degree. We’re just hoping instead of them going from the 10th floor and dropping to the fourth floor, hopefully, they only drop to maybe the seventh floor. Then the climb back up is not as hard. But with that said, inevitably you are going to decondition a little bit after this ACL injury. It’s just a natural tendency of this process.
If you have the perfect system and this is your full-time job, you might not lose that much. But in most situations, most ACL injuries, high school athletes we’ve worked with, college, and then when you start talking about people who are recreational athletes, there’s a lot of life pieces that they can’t just take off extensive periods of time to just focus on this. And then we’re talking about the resources as well. This is pulling from my time as a physical therapist for the past five years and working with ACLers exclusively now and have worked with hundreds of ACLers, and as a strength conditioning coach for over 10 years now. And it’s not an easy process to just build these athletes back up, especially whenever you’re dealing with the presence of a complication of the body and when you’re thinking about an injury and pain and swelling. And then we talk about all these other factors that could be playing into it, whether spinal cord or brain-related changes. These are all pieces that we have to figure out. And that’s why this ACL injury, this recovery is not easy.
If you’re listening to this thinking, man, this has been a hard ride. That’s totally fair. I had my own hard rides with my own two ACL injuries with many of the ACLers we work with. They have bumps in the process, and it takes time for all of this. And if you are seeing people online, social media, I think can give this fake mirage of, oh, I’m doing well, or I’m crushing it, or look at me doing this thing at three months. And then you could probably go and find 10 other stories of people who are struggling. And so this is the thing that sometimes can get missed with social media and it depends on what you’re looking at. Just a small little caveat here: Be mindful of what you let into this process and how you compare yourself. But just know, it’s complex, it’s hard. We don’t have it figured out. And that’s why we have high re-injury rates or people not going back to the things they love. And we can sit here and list 30 different reasons why because of X population. But this is something that is important to bring the light and understand that it does take time, it does take a lot of work, and it does take a lot of guidance and very specific expertise to be able to help walk you through this process.
Now that I’m off my tangent, I’m going to continue with our conversation about the nine months. It allows us to really build up these qualities with hopefully enough time. That’s the big thing about the nine months. Sure, the healing process is important, but it allows us to build up these qualities. And that’s what I’m going to keep referring these to the athletic qualities that we need to build up, that I work with, with any single one of my athletes, to make sure that they have the capabilities and the capacities to do this. And it’s so important. And even with the perfect guidance and expertise, you still may not get there in those nine months.
Sure, we’re going to target that, but it might be a little bit later. You might be earlier. As I had mentioned, that bell curve. And some of this is always going to come down to the goals for the person, their risk tolerance of getting back to certain things, and then just also thinking about the longevity of the health of the knee, as well as just longevity for your body and how you want to utilize it which is very important. But most people don’t fall into this rushed category of getting back to sport besides a very small percentage of people like pro athletes or someone who’s trying to make a certain scholarship. Or there might be this one-time-in-a-lifetime-type situation, then you may need to risk it. But 90%, if not more, don’t fall into this category.
I want to continue to focus on the nine-month timeframe that is often touted and mentioned in this message that I got. And so what happens is that when people are told this nine-month timeframe without given any other context or any other prerequisites if you will, where they need to pass certain criteria. It can give people a false sense of security. If they think that, oh, when I hit that nine-month timeframe, I’m good to go as long as I just do enough. But I think that do enough is where people can run into problems, and if they really do lock into that nine-month timeframe.
Now, I do understand that we need to anchor ourselves to time. I get that. That’s why I don’t give people a hard time if they’re like, hey, by three months I want to do this, or three months I need to start running, or the protocol says that. I think where it runs into trouble is when people have a mismatch of expectations and it’s not constantly updated along in this process based on their progress and where they’re at. And what does the next 2, 4, or 6 weeks look like? All of our athletes have targets in those timeframes to be able to work towards, especially in the short term, understanding the long term and knowing that constantly needs to be updated based on criteria. We use the time to help associate that based on our expertise, and understanding of how long that’s going to take to develop. But if you are only at a 50% quad deficit and you want to run in two weeks, it’s not going to happen. It shouldn’t happen.
But that’s where we have to know the physiology of the gain, how your knee responds. And giving you a good timeframe to be like, okay, well, if it’s at 50%, maybe we can get it there in the next four to six weeks. And then see if we can get you that extra 20% and make sure it’s at a good enough absolute value to make sure that it’s good for your body weight and you can start running along with other criteria we’ve tested. With that said, the nine months can give that anchoring point, but we want to make sure that we don’t get too caught up in it just being a healing standpoint and not this quality development standpoint. Those nine months serve as the proxy to prepare for those two things, healing and developing the physical qualities and preparedness to do those goals that you want to do.
Let’s say someone has surgery, subpar rehab, no return to sports testing besides maybe a hop test. And that’s not even a good return to sport test anyway. But let’s say they do that and then they get to the 9 or 10-month mark and they say they feel good, whatever that means to them. I don’t know, but that means they feel good. Maybe the knee feels normal with the things that they’ve tried to test it with. They feel okay. The gym-based stuff is going well. But let’s say they want to go back to basketball and they’re trying to do their thing. But they haven’t really done much basketball practice, they haven’t done any of the testings, they haven’t done any really good programming or rehab, maybe some gym-based exercises. Should they go out and play? What are the determining factors? Being beyond nine months and a hop test? Now, let’s flip this. What’s the information that would potentially say they shouldn’t? Poor rehab, no return to sports testing. What’s a stronger argument here? When someone passes that nine-month threshold after ACL reconstruction, they don’t magically cross that threshold and automatically have a reduced risk. I don’t think so. And I think that the research… sometimes if we kind of look at this stuff, we’re like, okay, for every month delayed, we have a reduction in risk.
We have to look a little deeper as to why that is. Whenever that month is increased or you have more months in association with that, it just allows you to have the knee to heal, have that ligament to heal, but it allows you to physically get more prepared for the thing you’re trying to do. And so that’s the thing that I want to really hit home here. It’s what’s done in those nine months and that nine months serving as a proxy versus the time alone that is getting the ACLer to that end goal and reducing the risk of re-injury.
I want to add to the context of this ACLer who reached out. He even mentioned the first six months of his rehab were pretty bad. You take the first six months of rehab and try to get back in nine months and said he’s at 11 months. Sure, you can make a lot of headway in those five months, for sure. But the thing is, when you think about that whole situation and basing it on time and using even a hop test to potentially try to verify that someone is cleared for sport, there’s just a lot of missing pieces here. And I don’t want this to be a case that is mismanaged because someone was given poor information. And so at the time of this message, he actually went and played a couple of times. The first time was fine. The second time the knee didn’t respond. So hot, swelling, pain, some issues, and again, this is not a client, just someone reaching out as we were trying to help support them and give some information.
And here’s how I basically look at this, even though you’ve played, it’s like going out in your car in crazy busy traffic, let’s just say Atlanta on a rainy day and not getting in an accident—you got lucky. And you could be totally fine. But if your car is not operating at 100%, the brakes aren’t in check, the tires aren’t in check and the gas isn’t in check. You know all these different pieces, oh, and you’re also the driver’s having to operate this. If that stuff isn’t operating at its best ability and passing all those tests to be able to utilize your car in traffic, you kind of run a higher risk of maybe a car accident.
In this same situation, you could think the same thing here. Of course, we’re not cars, but there’s a very similar analogy or connection to this where I’ve seen this too many times where people get this false sense of thinking enough time has passed and they’re thinking, I’m good enough. I feel pretty good. But my follow-up question is always by what measure and what preparation? What was done to make you think that? If it’s just going to the gym and doing some strength work, that’s great. But if the sport you’re trying to get back to as running, cutting, pivoting, and you’re sprinting and you’re jumping, and you haven’t done that to the exact intensity of that said sport in a progressive manner and also taken into the account the different reactivity of the sport. When you think about a sport like basketball, you’ve got different players and teammates on the courts. You’ve got defensive players, you’ve got different plays you got to run. If you’re doing that, you got to think about what the score is, the time is, you got to think about what you’re going to do and how to basically deflect somebody or defensively try to get in front of somebody. There’s so many different things that you have to about that you can’t think about your knee. And then you got to think about operating your body to do the thing, but you can’t really think about that. You have to think about the sport and what the next anticipation of your basic perception and action is going to be and vice versa.
And the only way to really know if you’re ready is to find proper testing. That includes strength testing, whether it is isokinetic or isometric testing. Worst case, you can do a one to five RM (repetition maximum) with maybe a leg press, knee extension, or leg curl. But that’s going to be a very basic entry point for that. We have to make sure we have the other pieces of this puzzle to make sure it’s comprehensive. The criteria have been cleared in order for you to get clearance for all of this. There’s strength testing, a proper and structured strength and conditioning program to address any gaps that might be between what you need to be cleared and to be able to make sure where you are and that program to help you get there. And then you need to make sure you can get cleared and have a sport progression to get back to the sport.
For this instance, basketball, especially given the nature of the sport and the contact and intensity of it can be. As of right now in the ACL space, there really isn’t any room for negotiating. It’s just a matter of if you want to be a part of that 20% to 30% re-injury group or not. And this is where you have to make sure that you have really good testing and you use really good guidance in order to make sure that you’re at reduced risk as possible. And I truly do think that 20% to 30% is actually a lower number. It’s an underestimated number. I think that is actually higher in this space, but we don’t really have a ton of information on recreational athletes, especially to showcase how much. A lot of it is done in more organized sports and there’s a lot of pro sports and a lot of the younger sports. But in terms of when you’re looking at true recreational athletes tearing their ACL, not a ton of data in terms of statistics. Because we’re always looking at youth athletes or pro athletes, at least from the research for the most part. But it does exist; it’s just not as much.
Now, in review today, it was focused on that nine-month cutoff and that expectation. It’s great to have a nine-month expectation before we were battling the six-month expectation, and we still battle that. And I think the big thing here is to help anchor us to what that nine months mean rather than just, oh, as we wait over time, that it’s going to lower our re-injury risk more and more. What it serves is as a proxy to allow that healing and to develop the qualities, athletic qualities we need. And also just that mental resilience and get that psychological readiness that we need to get back to that sport and activity. That still may take time. But if you’re physically ready and you’ve passed those tests, then that’s the thing that will allow you to get, especially into that mental headspace where you can start to feel more confident in yourself.
I remember that I was able to do all the things when I hit the nine-month mark. But then as I got closer and closer, and especially to a full sport, it took more time for me to get to that full place of confidence without thinking about my knee. And that was roughly around the year mark for myself. And the last analogy that I want to give here is that if you are progressing from grade to grade, it takes, let’s say a year on average in most of the education system. But let’s say you went to school for only 20% of the time. Do you think you should move forward to that next grade? And have you met the right testing criteria to do so? Just because you’re a year older, so you should move forward, right? But what if you haven’t really passed that testing criteria or you really didn’t show up for school much? This is like the nine-month window time passing in ACL rehab, but not really having great rehab or doing the work. It’s time, but what you do within that time matters to allow you to move forward. Make it count and don’t let that nine-month cutoff give you a false illusion. You’re good to go. Find good rehab, get tested, especially test your quad and hamstring strength, meet the proper criteria, and this is how we will reduce re-injury rates and allow people to get back to what they love.
That is going to do it for today, guys. Thank you all so much for just hanging out with me, for your support, for listening, for your time, for your attention. It really means a lot. And our goal is to just really keep pushing this profession forward, to improve the ACL space, to redefine what it looks like from our lens. And we appreciate you just for the ongoing support. And if we can ever be of any help, please let us know. What’s that saying? “It takes a village… And we’re slowly building a village.” Until next time, team, this is your host, Ravi Patel, signing off.
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