Most athletes and weekend warriors that tear their ACL believe that getting a new one is like getting a bad part replaced in their car. You go in for some surgery and after a while, you’re good as new. But is that really what ACL reconstruction recovery looks like? Not so much. Will you return to sports just like before? Some new research shows that the answer is a resounding “Maybe”.
Before we can get into ACL reconstruction recovery, let’s quickly review ACL tears. The anterior cruciate ligament—the ACL you hear a lot about in sports—connects the femur to the tibia and is key to knee stabilization and function. It prevents the knee from going too far, from hyperextending, so you don’t kick yourself in the face or look like Gumby.
Found in the middle of the knee, the ACL is critical for quick movements, for cutting to the hoop on the basketball court or sidestepping the baseline in a tennis match. Tears in the ACL can be caused by contact—as with the great Denver Bronco running back Terrell Davis—or simply through an intense change of direction with no contact at all. Athletes often feel that scary “pop,” followed by intense pain and swelling.
Though the Medial Collateral Ligament (MCL) is the most common knee ligament injury, it often heals on its own (3)—while a significant ACL tear usually requires either precise injections of the patient’s own bone marrow cells or surgery (4-6). Though ACL Reconstruction surgery (ACLR) has been common since the polyester days of disco, the long-term consequences of returning to competitive sport (or dancing) remain inadequately studied.
The New Research
A recently-published study hopes to shed some long-term light on ACL reconstruction recovery and returning to play sports after ACLR (1). Of the 93% of participants who responded to a questionnaire, 83% returned to play pivoting sports after early ACLR, but only 53% attained a preinjury level of competition. Males and females return-rates were similar, but males had an average career of ten years after injury compared to four years for females.
Twenty-eight percent of those who returned to competition experienced contralateral ACL injuries against only 4% for those who did not return to play. The combined reinjury rate of both groups when returning to preinjury level of play was 41%.
As with Terrell Davis, the study showed that ACLR did not guarantee patients a return to the preinjury level at their chosen sports. The study concludes that those who return to pivoting sport competition after ACLR do so at high risk for contralateral ACL injury—noting that after routine follow-up has concluded, significant ACL reinjury can still occur.
Other Problems with ACL Reconstruction Recovery
These results are also mirrored by other studies. For example, a 2016 study of ACL reconstruction recovery following patients 5-20 years after injury found that 39% returned to play competitive sports, 28% returned at a lower level, and 32% did not return to sport (1). Also, many other studies have shown problems with ACL surgery:
- Two-thirds of teenagers who have ACL surgery will end up with knee arthritis by the time they’re 30.
- The usual surgical technique leaves the joint rotationally unstable, as the normal ligament is better at stabilizing the joint.
- There is a loss of the normal performance in the knee due to ACL surgery.
- As shown in this study, the likelihood of tearing the other ACL is high.
- ACL surgery doesn’t prevent arthritis
Avoiding ACL Surgery?
Can you avoid ACL reconstruction recovery by skipping the surgery? In about 2/3rds of the cases, we can help the ACL tear heal in the knee by using a precise injection of the patient’s own stem cell rich bone marrow concentrate. This is a technically demanding procedure that uses real-time x-ray to confirm placement, but the results to date have been very good (4,5). Below is a video that reviews that procedure:
The upshot? The research shows that ACL reconstruction recovery isn’t what most people believe. As the studies show, about half of the patients or more won’t return at the same level of play or at all. So ACL surgery is just one way to try to fix the problem that has positives and negatives.
(1) Lindanger, L., Strand, T., Mølster, A. O., Solheim, E., & Inderhaug, E. (2019). Return to Play and Long-term Participation in Pivoting Sports After Anterior Cruciate Ligament Reconstruction. The American Journal of Sports Medicine, 47(14), 3339–3346. https://doi.org/10.1177/0363546519878159
(2) Filbay S, Ackerman I, Russell T, Crossley K. Return to sport matters—longer‐term quality of life after ACL reconstruction in people with knee difficulties. First published: 11 May 2016. https://doi.org/10.1111/sms.12698
(3) Andrews K, Lu A, Mckean L, Ebraheim N. Review: Medial collateral ligament injuries. J Orthop. 2017;14(4):550–554. Published 2017 Aug 15. doi: 10.1016/j.jor.2017.07.017
(4) Centeno CJ, Pitts J, Al-Sayegh H, Freeman MD. Anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow nucleated cells: a case series. J Pain Res. 2015;8:437–447. https://www.ncbi.nlm.nih.gov/pubmed/26261424
(5) Centeno C, Markle J, Dodson E, et al. Symptomatic anterior cruciate ligament tears treated with percutaneous injection of autologous bone marrow concentrate and platelet products: a non-controlled registry study. J Transl Med. 2018;16(1):246. https://www.ncbi.nlm.nih.gov/pubmed/30176875
(6) Mahapatra P, Horriat S, Anand BS. Anterior cruciate ligament repair – past, present and future. J Exp Orthop. 2018;5(1):20. Published 2018 Jun 15. doi: 10.1186/s40634-018-0136-6