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Brian Schiff’s Blog

Injury Prevention, Sports Rehab & Performance Training Expert

Tag: ACL injury

Over the years, I have been fortunate to work with lots of athletes ranging from youth to professionals. Regardless of age or skill level, I have observed that each one approaches the recovery in their own way. Some are eager to tackle therapy, while others are apprehensive and fearful.

To be clear, the mindset of the patient is as important, if not more important than the physical part of the process as it relates to success. With ACL rehab, I pay close attention at post-op visit number one to determine if the patient is a coper, non-coper or somewhere in between. Having this awareness is crucial as I look to encourage the client and position him/her for success in the fist phase of rehab. The mindset of a patient recovering from their second or third ACL tear may differ greatly than that of a first timer.

With that said, assessing the state of mind of any athlete in the PT clinic is a must. An athlete’s identity, confidence and self-worth is often tied to his/her sport. Injuries separate the athletes from their teams and take away something very important to them. This can lead to depression, anxiety, anger, fear and loneliness to name a few.

It is imperative to connect with an athlete in the first 1-2 visits of rehab. I aim to bond with them and ensure they know I will do everything in my power to get them back to their prior level of performance. Fear of loss is powerful, and I want to partner with them to prevent the loss of playing time as quickly and safely I can though proper rehab.


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Unfortunately, I see far too many patients following ACL reconstruction in my sports medicine practice. In any given month, I am rehabbing between 10 and 15 patients who have lost their season to this injury. Most of the time it is a non-contact mechanism of injury, often involving additional trauma to the collateral ligaments, menisci and/or cartilage within the joint.

Throughout my career, I have rehabbed several hundred athletes with ACL tears. It has always been an area of interest and passion for me as well as prevention. Blending my background in performance training with rehab, I have fostered through much trial and adjustment what seems to be a very effective approach to rehab and return to sport.  Rehabbing higher level athletes is much like working on a high performance sports cars.

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If you own a high performance vehicle, you would prefer to have it serviced at a dealership where the mechanics are experienced working on similar cars, yes? I feel the same care and application is relevant with ACL rehab.  PT that is too aggressive or too conservative can impede progress and negatively impact peak performance.


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As a sports medicine professional and physical therapist working with lots of athletes after ACL surgery, I am always looking for ways to improve post-op rehab and prevent a subsequent ACL injury. While we have lots of research looking at neuromuscular, genetic, sex and morphologic risk factors, we have not been able to make significant progress in injury reduction.  So many athletes suffer the dreaded “pop” making a simple athletic maneuver they have done a thousand times before.

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Based on nearly 19 years of experience training and rehabbing athletes from youth to professionals, I see strong links to a genetic predisposition (family history and prior injury) as well as concerns over neural fatigue. We already know the age of injury is a significant as research indicates those tearing at a younger age (around 20-21 y/o) are more likely to suffer a second injury. But what we know less about is the impact of ankle biomechanics (namely limited dorsiflexion) and how proximal weakness in the hip affects injury risk.

The latter topic was the focus of a study just published in the current edition of the American Journal of Sports Medicine. In this prospective study, researchers sought to determine if baseline hip strength can predict future non-contact ACL tears in athletes.


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Why is it that athletes performing a movement they have done so many times suddenly tear their ACL?  We have been studying ACL injury and prevention for many years now, and despite our best efforts, we have not made marked progress in preventing the number of ACL injuries.  In addition to anatomical variants and perhaps some genetic predisposition, I feel that the earlier push for sports specialization in our society resulting in increased training/competition hours is a major factor.

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The term ACL fatigue may or may not be familiar to you.  But in essence, this theory would suggest that after a certain number of impacts/loading, the ACL becomes weakened and less resistant to strain.  You could almost compare this to a pitcher who suffers an injury to his medial collateral ligament with too much throwing.

As someone who is consistently rehabbing athletes with ACL tears and screening athletes to assess injury risk, I am always interested in how we can keep people from suffering such a devastating non-contact injury. A recent article in the American Journal of Sports Medicine sought so assess ACL fatigue failure in relation to limited hip internal rotation with repeated pivot landings.

We already know that hip mobility is often an issue for our athletes.  Researchers at the University of Michigan sought to determine the effect of limited range of femoral internal rotation, sex, femoral-ACL attachment angle, and tibial eminence volume on in vitro ACL fatigue life during repetitive simulated single leg pivot landings.


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Every month there are new papers on ACL surgery and rehab appearing in the literature.  I do my best to stay up on them as this is one area of my practice I am extremely passionate about.  I am driven to understand as much as I can about both prevention and rehab, but find myself increasingly focused on preventing secondary ACL tears in my patients.

I feel poor movement patterns, muscle imbalances and inefficient neuromuscular control are major risk factors for athletes suffering a primary ACL tear.  We also know being female markedly increases injury risk.  Research also tells us that males are more likely to suffer a re-tear of the same side, whereas females are more likely to suffer a contralateral injury.

A study just published in the July issue of the American Journal of Sports Medicine looked at the incidence of second ACL injuries 2 years after a primary ACL reconstruction and return to sport.  In a nutshell, the findings were:

  • 24 months after ACLR and return to sport, patients are at greater risk (6x) to suffer a subsequent ACL tear compared to young athletes w/o a history of ACL injury
  • Female athletes in the ACLR group are 5x more likely to suffer a second injury
  • The contralateral limb of female athletes is at greatest risk

Click here to read the full abstract

This information is not surprising as I have seen it firsthand in 17 years as a physical therapist.  What we do not have much information about is how do the younger patients (e.g 15 and under) really recover from this injury.  When should they be cleared?  I worked with a young female soccer athlete who tore her ACL and medial meniscus at age 13.  She worked diligently with me in rehab 3x/week for about 6 months and then continued training with me at least 2x/week until she was about 1 year out from surgery.


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