Episode 211 | Breaking Down the 3-Step Return to Performance Continuum After ACL Injury

What is up team and welcome back to another episode on the ACL Athlete Podcast. Today, we are talking about return to performance. A lot of times people use return to sport. Today, I’m going to use that synonymously with return to performance. Because in our three-step process or our continuum, we are looking at return to sport is actually a second step to the final step which is full return of performance. I’ll break all this down. But just know that the full return to performance and return to sport are different, but oftentimes people will use this synonymously of getting back to the thing that they want to do.

Return to sport and activity is always a huge topic and one that athletes care about the most. When this ACL injury happens, it’s one of the first questions we get. When can I …? When can I play? When can I go do X, Y, and Z? It’s a challenging question as a physical therapist, as a coach, as someone who is helping, guiding someone in this process, because it can really vary in terms of timing. And we always use this anchor point of 9 to 12 months where we know the ACL is in a good place. Typically, after the nine-month process where it has biologically matured. It’ll keep maturing likely up until two years and beyond that, but we know the integrity returns to a certain point where we can trust at nine months’ return to sport, rates are higher and reinjury rates are lower in general. Now that can also coincide with the fact that we need a good amount of time to get athletes built back up to a level where they feel like themselves performing at the same level and not having all these compensations or deficits between leg and leg. That’s important in terms of the timing. But 9 to 12 months feels general. 

Now, with that said, when we try to answer this question: When can I…? When can I do X? When can I play? What about when can I practice with my team? What about sports that are not so structured and organized, if you will? What about recreational sports? Like the 22-year-old that wants to go play flag football, for example. They don’t have all this structure where there’s a coach and there’s a team and there’s ways to formally do all this. It’s a little bit more unorganized. You’re just recreationally playing. You want to get back to doing that thing but how do you do that? You either call on friends or figure out some sort of organization around it because it’s a little less structured. Or what about the 30-year-old that wants to play pickup soccer?

Another challenging piece that we see a lot of athletes run into because when it’s a high school player, or a college player, or a pro-level player, there’s always excess players and it’s easier to organize. When it’s pickup, you’re jumping into a game. You don’t know everyone who’s playing, unless you just go with a consistent same group of people, then it might be a little bit easier, which is what we end up seeing people do and helping and guiding people to do.

How do we navigate getting these ACLers reexposed to these demands? The different sports, the different forces, the speeds, the contact, just the general overall complexity of what sport and activity demands of them. And what about athletes who are trying to get back to specific activities, skiing, hiking, skateboarding, jujitsu, trail running, Crossfit competitions, playing with their kids. If you can name a sport, we have worked with it. And there have been some wild sports that people have shared with us or activities that we’re like, I didn’t even know this existed in the world. And they do. The thing is we are trying to help people get back to these things and we have to help them navigate returning back to it. This all comes back to the question, when can I do…? When can I do X? It’s a tough question and that’s where we have to zoom out and look at this process as a whole. And especially as we’re getting closer towards doing the thing and getting back to that sport or activity. We want to make sure we are operating from these principles and having a framework to help us and our athletes to get back to their sport and activity.

I’ve touched on this previously, which you can check out the previous podcast episodes on the particular principles: the four guiding principles; physical preparation, number one; number two is psychological readiness; number three, graded exposure; and then number four load management. These are four guiding principles that I use, that our team uses that you probably see any good physical therapist, performance coach, people who are helping other athletes navigate back to their sports or activities. These are typically some guiding parameters around this.

Now with that said today, I want to focus and zoom out a bit more from these principles, they’ll be operating throughout the whole process. But I want to zoom out and be able to talk about this three-step continuum for return to performance. Now this is something that was initially mentioned in Ardern’s paper, the 2016 consensus statement on return to sport for the first-world Congress and sports physical therapy. Now this has been used and reiterated on a consistent basis over the years since then. It’s a great, simple framework to utilize. And the three-step approach in this continuum goes: Number one, return to participation; number two, return to sport; umber three, return to performance. 

Now I want to walk through each of these to help you guys understand this process and how we might walk athletes through this. It’s important to understand each and every step because each step builds on the previous one. Therefore, we can’t skip any steps and you might hear them referred to other things, like return to participation might be returned to training, for example, or return to practice. It’s synonyms for the exact same thing. You’re getting exposed back to the thing in some way, shape or form.

When we talk about return to sport in general or return to performance, just know it’s not just a magical day. It’s a process and it is a continuum that is methodical in progressions. I think that this is important because I think sometimes people will assume that it’s like, Oh, I’ve been cleared. Here’s my graduation day and I’m good to go. And while yes, there will be a point where it is communicated that you no longer need to be as focused on rehab or you can go back to playing your sport, just know that this whole thing is a process. It’s just not going to be this pass or fail thing on one specific day. But it’s accumulating data points and progressions over a period of time to make you ready for the demands of your sport or activity. And that’s going to be super important because that’s what this is going to help so much to do. 

This applies more logically to organized sports, but it also applies to other activities as well. And we use this for every single athlete we work with, and we might just adopt this continuum based on the particular sport or activity. Like skiing, for example, we might have some sort of progression for this of getting on your skis and then being able to do some bunny slopes and greens and then maybe working towards blues and then blacks. These are things that we start talking with our athletes about based on the mountain, based on their comfort, based on the minutes, how their knee responds. We have specific parameters within this as well to help people back to this. It doesn’t have to be just this soccer sport or getting back to football or lacrosse or soccer. It could be more than just an organized sport to apply these principles to in this continuum. 

I want to talk about first return to participation. This is where the athlete will be participating in rehab, but they will also be doing some training. They might be doing some modified training sessions for their sport or activity. This could be just drills, for example. It could be maybe decreased time within practices, the intensity, the amount of contact they’re having, or maybe it’s a different position. If you are talking about a more organized sport, these are all options. But they’re not at a level yet where they could truly start playing their sport and have a full return to sport. And that could be due to they’re still healing. Maybe the physical preparation isn’t fully there. Mentally, they could not necessarily be there and there could also be other factors too that they have no control over. This is return to participation where they’re participating in the thing but it’s in a very modified sense while they’re still doing rehab. 

Let’s move on to number two, return to sport. And again, this is the second step out of the three-step continuum for return to performance. Return to sport is when the athlete is back to playing their sports. They’re participating in it, but they are not at their desired level of performance. And there are some athletes who might be okay being here. They might have had this ACL injury and let’s say they were ex-athletes in high school and then they just want to play pickup in college or just recreationally. This might be where someone potentially stops. And they don’t want to go any higher or have higher levels of competition. And they may stop in this return to sport phase where they’re not necessarily at the level they were before, but they can participate in it. That’s why it’s really important that we always talk with our athletes and understand what they define as where they want to be at the end of this process. Because if you have someone who is two ACLs in, they might be changing their mind about participation in sports and doing other things. Or maybe three ACLs, or maybe it’s just not worth it. This is super important for us to know about an athlete. 

And then there’s also the other athletes who are like, well, I want to go back to the thing and I want to compete and I want to be at a high level. Well, this is step two out of three. So then next we’re looking at return to performance. This is where the athlete is performing at or above their pre-injury level. Now this is our goal. We don’t necessarily want to just say, all right, we’re returning to sport, taking it within the context of this episode. We want to make sure athletes return better than they did before. And we want to make sure that they can come back better and they should know that right with hard work, being able to stay consistent, being able to hit the right numbers, the proper exposure to the thing that they’re trying to do, that they can come back better. It’s an opportunity to do that through this ACL injury. This also means you might continue to beat strength levels and performance levels. PRs are something that people are potentially achieving in this particular final phase. This is where that performance is continuing to grow and they’re starting to surpass those pre-injury levels. And so that’s where we want to get athletes back to. 

When we’re working with people, we want to make sure that we’re in this to first define where it is that they want to finish up and be and get back to. But then also like our ultimate goal is to get them back to return to performance. We don’t want to stop at just participating sport, we want to get them back to the thing better than they were before. And I think it’s important to understand this model because we need heuristics to guide us. We need essentially these rules of thumb and things that are proven in the research and ways for us to make sure that we aren’t just throwing things at the wall and seeing what sticks. We need to make sure that we can have athletes physically ready, mentally ready and be able to gradually expose them back to the thing and be able to make sure we manage the load as they do that. That way their body responds and adapts appropriately. That’s going to be so huge in this process. 

This return to participation, sport and performance process can look so different depending on the injury.  If you have like a grade one ankle sprain, it could be something that within the next week or two, you’re back at it. But with that said, the more major injury it is, the longer this process is probably going to be. This doesn’t necessarily mean, oh, this starts at month nine, for example, and then you get to take the next three months to do this. It can exist anywhere on the continuum, but we want to make sure when you step into return or participation, it aligns with your physical and mental readiness because we want to make sure you can tolerate the modified sessions and be able to continue to do your rehab and training and not let that take the backseat. But you’re not ready to do the thing yet, but we want to start introducing it. Maybe it’s just, non-contact drills. Maybe it is just literally just skills-based work that you are doing by yourself. There are a number of things that this can be included as, and it could start month three, month four, month five, maybe you’re in month nine or 10, and that’s the timing of when it needs to start. And that’s where it will be individual case-by-case basis. But at least we have this process versus what we typically see is that people will “graduate.” And that might be they get discharged from their physical therapy because insurance runs out or they’ve exhausted what they can provide for you. And you still might be four or five months out and still need a lot more to build up in terms of your rehab. Or it could be the surgeon clears you because you’re at six months or nine months and they did a quick exam. But with that said, it doesn’t mean that it’s just like a flip of a switch and then you’re ready to jump into a sport. It needs to be fully assessed based on readiness. And that’s one thing to assess is just your physical readiness like how’s your range of motion, how is your strength, how is your jumping abilities, your cutting abilities? How is your conditioning all these different criteria and metrics we’re looking at for athletes to make sure they are fully ready to go.

But in addition to that, there’s also a sports-specific phase, which is this return to participation, sport and performance. We walk athletes through this process week by week, giving them structure and parameters around it and making sure that they don’t hit it too hard, for example. And also make sure that they’re building their confidence as they go. But this is just a very simplified framework and continuum to use for this that I hope that you can put into play for yourself, or if you’re a PT or coach listening to this, that you can just start to think about, okay, I’ve got this athlete. How can I think about these three-step continuum and really think about nudging them forward. I always use the dimmer switch as an example, instead of it being this light switch of like, all right, cool, you pass your strength tests, go out to practice. Instead, we want to put parameters around practice and say, all right, well, let’s say these are green light things we feel good with, this is yellow light things we feel good with and these are red light things that we’re like, this is a no go. And that will help to be able to create some parameters for athletes. Therefore, they feel comfortable being able to step back into it without feeling like they’re so overwhelmed, or maybe there’s fear that’s setting in because they’re just not sure where to start.

I hope that this is helpful team, something that we reference all the time, we teach our mentees all the time within this and you can find this all across different research studies. But just a very simple three-step continuum for return to performance, return to participation, return to sport and return to performance. That’s our goal. And I hope that’s your goal as well to get back better than you were before. Until next time team, this is your host, Ravi Patel, signing off.