What if you and the surgeon have different return to sport timelines after ACL reconstruction?

Hey everyone!  I have the pleasure of being joined by Dr. Kyle Matsel. We get tons of questions about our ACL reconstruction rehabilitation courses on MedBridge, where we take a person from early stage rehab all the way through high level performance.

One of the questions that we get surrounds return to sport timing or discharge from rehabilitation timing, where research indicates it's a minimum of nine months and it might need to be even up to a year. Whether they return at nine months or not, rehabilitation should be a full-year process.

How do you navigate working with the surgeon who says to the patient, even before surgery, "You'll be back to sport at four months or six months or you'll be better at six months and you'll be full good to go?"

Yet we know from the research, and we know from our best outcomes, that it probably is nine or twelve months.

But yet the surgeon did the surgery. How do you navigate that? It's kind of a tricky subject.

Kyle:  It really is. I really appreciate the question because it's real life when people are literally dealing with that all the time when managing these athletes. One thing you need to think about is in a little bit of an advertising mode, little bit of a marketing mode too because there's obviously competing physicians. They may be in the same town or same community, same regional area that are doing ACL reconstructions as well.

And if you have one physician A who's saying, "Hey, I'm going to get this person back to sport at six months," and physician B says, "Well, it's going to be a year for us." And from a patient or an athlete or a parent standpoint, which one are you going to go with? And from a superficial standpoint, it sounds really good. Just say, "Oh, I'm going to definitely go with the person that can get me back the soonest." Right?

And I think it sets rehabilitation up to sometimes be a little bit hamstrung. The expectations then are you're going to be back running in three months and four months and jumping and then back to sport and discharge at six months. And we know that that's not always the case. Most of the time is not the case for our athletes. So the conversations that I tend to have with the physicians really are geared more towards the individual patient and how they're doing in rehab. And for that, you really have to have very clear objective measurements, biomarkers, milestones. You have to come with the physician with some reason or some data, right? If you just say, "They're just not ready yet" or "Yeah, we really need to just get to nine months. "Even if that's what the research says, that's a hard sell for the physician who did the surgery and really has ownership to get them back.  So I think that's where doing lots of testing, getting lots of information, saying "Their power is down. Their strength is not quite where it needs to be," and having that plan in place can be really powerful.

 Phil:  Absolutely. In addition to that, I think that communication early and often and addressing that communication on two fronts. One is doing some education with your physicians and saying, "Let's talk about how you can talk about this with your patients. Here's the research that says nine months really reduces re-tear rate."  And maybe they can talk to their patients about, "Most physicians, and including my surgeries, you can kind of go back at six months, but we have to understand the risks involved of that versus nine months."

The other one is discussing biomarkers, like you said. Let's agree on those biomarkers...let's put these down . .  that this is what strength is going to be, this is what hop testing, balance testing, movement, endurance, power and agility are all going to be at this level. And let's agree to those in advance with the surgeon. That's one area of education. And quite frankly, sometimes that works, sometimes it doesn't. It really depends on the physician. I find the better relationship I have, the better it works.

And with my patient I don't go against the physician. But what I might say is, "Hey, Dr. Smith may have told you that you're going to be ready to go at six months. That's from a surgical perspective.  My role is the rehabilitation and my role is to help you with that process. And so here are the biomarkers that we're going to be looking at. And also here's the research about returning earlier than nine months."

And I'm not saying that that's an absolute no-go before nine months, but we all need to be on the same page about risk of re-tear, risk of tearing the opposite ACL and what that actually entails and what does long-term look like. Because one thing I think we have to recognize, too, is there are certain situations where I will return someone before nine months.

One clear scenario might be as a senior in high school to be able to complete that senior season. They don't plan on playing in college. My goodness. Yeah, we're going to try to get them back as safely and as effectively as possible, but we're going to balance that risk. Do you have any thoughts on that?

Kyle: Yeah, I think that the negotiation piece a little bit is nice with the patient, and it's like, "Hey, we are setting you up for a six month or a seven month plan because you need to get back for your senior season. But just keep in mind that things can change. A lot of variables can happen within that time frame. And if your power isn't where we want it to be, if your movement isn't where we want to be, if your pain isn't where we want you to be, then we may have to extend that a little bit more." So again, it's a little bit of a motivator too, for the athlete. But they always are kind of aware of if I do choose to go back earlier than we would feel comfortable with them going back, there is a little bit of elevated risk. Now, the other mistake I think we make in rehab sometimes is we say, "Oh, you're back to sport, therefore let's just stop seeing you in rehab." 

And I think that this is really the clear discharge and return to sport is not the same thing. And this is a perfect example of, "Okay, you're a senior. Let's go ahead and start getting you back into some limited minutes, into playing time so you can have that senior year. But at the same time, if you're going to have a problem, I want you to have a problem while you're still under my guidance and my tutelage, because I want to be able to mitigate those problems and continue to advance you in the rehab process throughout the entire duration of the plan of care." 

Phil:  Absolutely. Well, that's some great thoughts. I think the key thing is we need to bottom line, educate our physicians, educate our patients, and ultimately, as a team, we're making that decision.  But I don't think we should just step aside and go, "Oh, well, that's what the doctor says." 

If you have any other questions, don't hesitate to reach out to us. We love answering questions. If you haven't seen our ACL Reconstruction Courses with MedBridge, check those out. Do you want to know how we rehabilitate people with ACL reconstructions? Check out our ACL Reconstruction Guidelines. 

We have a lot of fun doing those and absolutely feel free to shoot us questions. We're happy to answer them at www.philplisky.com and www.kylematsel.com.

About  Kyle Matsel PT, DPT, PhD

Dr. Matsel is faculty at the University of Evansville where he teaches in the musculoskeletal content areas of the Doctor of Physical Therapy curriculum. He received his Doctor of Physical Therapy degree from the University of Evansville in 2011 and his PhD in rehabilitation sciences form the University of Kentucky in 2021. Dr. Matsel is the director of the ProRehab & University of Evansville’s Sports Physical Therapy residency program. He is a board-certified clinical specialist in sports through the American Board of Physical Therapy Specialties and a certified strength and conditioning specialist