Brian Schiff’s Blog
Injury Prevention, Sports Rehab & Performance Training Expert
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Have you ever experienced a significant injury? If so, do you remember wondering if you would ever be whole again? Pain, fear and the inability to do your sport or physical activity can cripple the human spirit.
Over my 21 years as a physical therapist and fitness professional, I have witnessed how powerful the mind is and how critical it is to have the right mindset to overcome physical obstacles. Some people are mentally stronger than others – period. With that said, adversity and pain has a way of testing the spirit and will of an individual.
In any given week, I see at least 5-10 patients rehabbing an ACL injury. The injury, surgery and rehab is physically and mentally grueling. The injury itself takes the athlete away from his/her passion or sport immediately, while presenting them with a long path back to full health. Many suffer an identity crisis as they become isolated and away from their peers. Physical therapy that fully restores function is a must in this group of patients. For more on what complete ACL rehab looks like, click here to read one of my previous posts.
Fear of reinjury and persistent knee symptoms are common reasons for a lack of return to play after ACL reconstruction. Click here to read an abstract regarding kinesiophobia in this group of patients.
With any injury, it is only natural to worry about the outcome. Clients often wonder quietly whether they will be able to return to their previous level of play. In this post, I want to talk about the elephant in the room for patients coming back from an injury, and that is a legitimate fear of reinjury.
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.
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.
So many times, athletes and parents alike are singularly focused on the physical rehab necessary after an injury. Often, what the athlete is not talking about is the psychological impact of the injury. Suddenly, their identity and self worth may come into question. They feel disconnected from teammates and coaches. Their daily routine consists of rehab and not practice/play. Deep inside their head they are quietly wondering, “Will I ever be the same again?”
Aside from some of the obvious questions that race through an injured athlete’s mind, one of the biggest and most often unspoken concerns is the fear of re-injury. Having worked with athletes of all sports, ages and abilities, I have seen firsthand how important it is for an athlete to go through a functional and sequential progression that assures that they are able to run, jump, cut, pivot and decelerate again without pain or instability.
I have worked with hundreds of athletes over the course of my career that have suffered ACL injuries. The longer I practice, the more I become convinced that we probably have been pushing or allowing these athletes to go back to their sports before they are really ready (physically and/or mentally). Six months has long been the benchmark for most orthopaedic surgeons. The graft is well healed, but often the mind and body are not really ready.
While I have seen athletes who have great strength, stability, hop testing scores above 90% and look good on movement drills, sometimes these same athletes still have asymmetrical squat patterns, FMS scores lower than 14 or apprehension about returning to their sport. In addition, fear of re-injury is a big factor that impacts confidence and readiness to return to activity.
Consider some of these facts about modifiable factors with return to sports after ACLR from the May/June 2015 Sports Health Journal:
- Motivation, confidence, self-efficacy, optimism and low fear are associated with a greater likelihood of returning to preinjury level after athletic injury and ACLR
- Lower fear of reinjury and greater pyschological readiness to return to sport favored returning to preinjury level after surgery
- Combinable data from 10 studies suggests that fear of reinjury, psychological readiness to return to sport and one’ subjective assessment of knee function were predictive of level of return to sport
- As many as 1 in 2 athletes who do not return to their preinjury level of sport report the main reason is fear of reinjury
For those who know me well, it is safe to say I am an “ACL geek” of sorts. I love studying, reading and searching for the best way to rehab and prevent these injuries. As I have grown in the profession, I have become increasingly concerned with articular cartilage damage and the long term effects it has on our young athletes.
Perhaps I am getting more concerned as my knees aren’t getting any younger either (lol). Anyway, I truly believe we often underestimate how deleterious cartilage injuries can be long term. In addition, I feel we, as rehab and conditioning professionals, need to better understand how our training impacts the cartilage regardless of whether patients had a concomitant bone bruise with their ACL injury or not.
One of my favorite prehab exercises is a single leg hop and stick (see below)
I typically begin with an alternate leg approach (push off right and land on left) prior to initiating takeoff and landing on the same leg to teach proper landing mechanics. By now, we know increasing hip and knee flexion, as well as shifting center of mass forward reduces ACL strain and injury risk through a diminished extension moment.
However, what we may not know as much about is how an ACL reconstruction alters tibiofemoral joint mechanics at such a landing. I want to share some interesting information from a recent article in the September edition of The American Journal of Sports Medicine. The article by Deneweth et al. looked at tibiofemoral joint kinematics of the ACL reconstructed knee during a single-legged hop landing.
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