Decrease Your Risk of Another ACL Injury
Every soccer girl has, at some point, come to hear of the dreaded ACL tear. Whether you have torn your ACL, or know someone who has, it is an injury that is all too well known in the soccer girl world, and ranks fairly high in the list of soccer girl problems.

The rehabilitation process after an ACL Reconstruction (ACLR) is a long and tough road. There are many peaks and valleys during the uphill climb to return to sport, and no two soccer girls’ rehab processes will look exactly the same, as each injury is slightly different and unique to the individual.

An important consideration to bear in mind is that while the majority of young female soccer players are able to return to their prior level of competition in soccer, there are some who do not. There can be many different reasons for this including strength and knee function deficits, fear of reinjury, pressure from parents, coaches, and teammates, and many other factors that can all contribute to whether or not a soccer player will have a successful return to sport. For example, you may be a senior in college who does not have any plans to play competitively after graduating. In this scenario, you may not return to your prior level of competition (college soccer) simply because you are done with that level of competition anyway.
Once you have completed a successful return to sport, it is important to be aware of the increased risk of sustaining another ACL injury. I know, the absolute last thing you want to think about after working so hard to get back on the field with your team is having to go through it all over again. We cannot simply ignore the fact though, that the number one highest risk factor of sustaining an ACL injury, is having already had an ACL injury previously.

Based on current research, the rate of ACL reinjury in athletes under the age of 25 who return to cutting and pivoting sports like soccer is 23%. One study found that the rate of ACL reinjury in athletes under the age of 20 is almost 30%. Taken altogether, our current body of literature shows us that young athletes who suffer an ACL tear and return to sports like soccer are at about 30 to 40 times greater risk of sustaining an ACL injury compared to athletes who have never had an ACL injury. To put it more simply, about 1 in 4 young athletes who sustain an ACL injury and return to cutting and pivoting sports like soccer will go on to have another ACL injury, and this will most likely occur within the first 1-2 years of return to sport.
This reinjury risk is not limited to the side that was previously injured; it also applies to the knee that was not injured. In fact, there seems to be a trend that young female athletes are more likely to injure the opposite ACL than the surgically reconstructed side (the rates are very similar though). The reasons for this are many, and not fully understood at the moment. However grim a picture this may seem, there is hope!

A study by top ACL researchers in Oslo (Norway) and Delaware showed that there are a few key ways that we can help reduce the risk of secondary ACL injury. You may have heard about athletes who recover from ACL surgery in about 6 months. You may have also heard about “accelerated rehab” that promises a shorter rehab period to get you back on the field faster. What we now know is that each month that return to sport is delayed, the reinjury risk is reduced by 51% up until the 9 month mark. That means that each person who tears their ACL and undergoes ACLR should wait at least 9 months before returning to sport.
Aside from waiting a minimum of 9 months to return to sport, it is also important that you pass certain testing criteria before being cleared to play. Your chances of ACL reinjury is reduced by 84% if you pass all return to sport criteria. These criteria include quadriceps strength limb symmetry index (LSI) which is the strength of your injured side compared to the strength of your uninjured side, single leg hop for distance, triple crossover hop, triple hop, 6 meter timed hop, and patient reported outcomes measures such as the KOS-ADLS and Global Rating Scale. Of all these tests, it seems that the most important one, and the one that predicts reinjury, is the quad strength LSI.

  A single leg hop test is often used in the return to sport testing criteria. Here, we are looking for the distance hopped on the injured leg vs the distance hopped on the uninjured leg, as well as the quality of your movement. Make sure you are landing with a bent knee and try to make as little sound as possible when landing.

Quad strength LSI is given in the form of a percentage. Typically, a passing score for quad strength LSI is 90%. This means that the strength of the injured side has reached 90% of the strength of the uninjured side. In fact, for every 1% increase in quad strength LSI, there is a 3% decrease in reinjury risk! That means that it is crucial that your quads become really strong during your rehabilitation program.

Split Squats and Lunges are great exercises to help you strengthen your legs. Once you are comfortable with the movement, go ahead and add some weights! Remember to work both sides.

Since we know that the opposite ACL is at least just as likely to be injured as the reconstructed ACL, it is important that you are strengthening that side as well after your surgery. One of the reasons for a high rate of ACL reinjury might be that the originally uninjured leg gets weaker as a result of decreased activity and focus on the injured leg. Then, when you go to test and compare the strength of your injured to uninjured sides, both are weak so even if you achieve . 90% quad strength LSI, you are really just comparing a weak leg to another weak leg and it does not mean you are ready to return to sport.
Going through the rehabilitation process for an ACL tear is tough, and it will challenge you. In order to reduce your risk of having to do it again in the future, make sure you are truly committed to your rehabilitation program and that you have a physical therapist who is experienced in working with athletes with ACL injuries. Focus on getting really strong in both legs, don’t rush your rehab, and be open and honest with your healthcare team, parents, coaches, teammates, and most importantly - yourself. If you’re told that you’ve passed return to sport testing, but you still don’t feel confident in returning to soccer, that is really important! You should never feel pressured into returning to play again if you don’t feel completely prepared and ready. Talk to your physical therapist if you have any concerns during your rehabilitation process and after you return to sport. We’re there to help you achieve your goals!

Blog Contributor: Nicole Surdyka is a Doctor of Physical Therapy, Certified Strength and Conditioning Specialist, and former Division-1 soccer player. She currently owns her own Physical Therapy and Sports Performance practice in Los Angeles with her husband, Marc, who is also a Physical Therapist. Nicole specializes in the rehabilitation and risk reduction of soccer-related injuries and is passionate about keeping soccer players on the field and performing at their best.  Reach out with any questions for Nicole on IG @dr.nicolept or on Twitter @NSurdykaPhysin


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