When should I return to sport after ACL surgery?

Good question. It depends.

Time since surgery is the most consistently used criteria. It is also the most misleading indicator. The calendar never knows when you are ready. Most people are told that it will take 1 year, but that is often under an ideal scenario. That scenario requires consistent adherence to your rehab program, regular checks of your progress and a long term commitment of effort, time, and money. Inevitably, many will drop off the program along the way.

Re-injury rates remain high following ACL surgery. Often because of incomplete rehab and because there are not clear, established benchmarks that determine success. Also, many people who suffer an ACL tear will never actually return to their previous level of activity. It is an area of big concern for many medical professionals.

Rehab professionals use a combination of factors to look at readiness to return—strength tests, functional tests (most often hopping and jumping) as well as survey information to see how good you feel about your knee. A study by JOSPT underscores how difficult the decision can be.

If the survey revealed you did not feel confident in your knee, you would most likely not pass the other tests and not be ready. However, even if you felt good about your surgery about 50% of the time you overestimated your ability and would still not be ready.

PT’s also know that just having good strength in your leg or being able to pass the hopping tests is often not sufficient to return to the field. A movement analysis is highly recommended in addition to other testing to give an objective measure of how confident you are in your leg. Can you change direction symmetrically? Can you absorb shock and generate power in the limb without making compensations? It helps determine quality not just quantity of movement.

There still is no simple benchmark to determine when you are ready to play. You need to complete all basic rehabilitation, you need to have good strength in the leg. You need to feel confident in the leg and you need to be able to pass a movement test. Most people that have ACL surgery cannot check all those boxes and most do not return to their sport.

The best news is that the calendar never knows when you are ready to return, but it also does not determine when you have failed to return. I have seen many clients pick up their sport after years away. There is no substitute for strengthening and movement training to regain confidence in your knee. All it takes to get started is a couple more clicks.

Can I improve my running form?

Yes you can!

Most runners I meet are focused on how much they are running and how fast they can increase their mileage to prepare for a race.

Few are focused on how they run.

With injury rates for running as high as 79% in a given year running retraining is a powerful tool to prevent injuries before they happen. It can also help you return to running faster after sustaining an injury.

Many runners are skeptical that real changes can be made, but a study published in JOSPT shows how effective simple tools can be. Visual and audio feedback can reduce the impact force of running as well as allow a PT to coach you away from stride characteristics associated with injury. It often only takes a mirror, recorded video or a metronome to dramatically change running mechanics. The great thing is you can notice the changes immediately.

The key is you need to have an expert analyze it and then supervise your initial training to make sure the corrections are being made. Once that’s done the practice is easily done during your already scheduled runs.

It’s simple and effective, why not give it a try!

Range Book Review

David Epstein’s outstanding new book, Range: Why Generalists Triumph in a Specialized World, details how a wide variety of experiences and training is more important to developing excellence at a skill than narrow specialization.

This is in direct contrast to the popular 10,000 hours rule that has been popularized. The idea behind this rule was that 10,000 hours of deliberate practice was the amount needed to master the subject (the original study was done on violin players but has recently been updated and largely debunked).

As Epstein argues through a comprehensive look at research, elite performers tend to have a diverse background of experiences. This is applicable to many areas of life but there is a focus on athletes in the book. Athletes that specialize too early limit their ultimate development. For many elite athletes, the sport they play professionally is a second or third choice.

It’s not always clear why a breadth of experience helps you excel in a sport, but there’s a compelling idea that by playing in multiple sports your body and brain learn new skills and approaches that they may not have developed with a more limited focus. An example, is a football player that learned his footwork from basketball or gymnastics. Likewise, a baseball player that played tennis could become better at tracking a ball with his eyes.

Epstein introduces the book with the competing narratives of Tiger Woods versus Roger Federer. Woods famously specialized in his sport at a young age and became the best in the world. Federer played a variety of sports at a young age and was behind his peers in tennis as a teenager before dominating the sport. The difference between their training is due to the differences in the sports. Golf is a fixed sport where you mostly compete against yourself and rewards deliberate practice. While tennis is a dynamic activity where you’re responding to an opponent and a constantly changing set of circumstances. Unfortunately for the early specializers, most sports and activities in life are in a more dynamic environment.

It is somewhat similar to how you learn a new task or become more skilled at a sport. If you try to improve at golf you can spend a lot of time just hitting balls and maximizing your ability to repeat a swing and you will get somewhat better. But, if your swing is flawed to begin with you will make even greater gains by retraining your swing. That is a lot more difficult and what usually happens is you get worse before you get better.

The same idea applies to other tasks and is a commonly used idea in Physical Therapy. To really master a skill you need to practice it in a variety of ways. A variable practice schedule increases learning more than a fixed one.

The ideas behind Range are especially powerful to a PT. Because while the upside is plentiful the downside of the way we are doing things now is readily apparent. The rise of specialization is correlated with an increasing amount of youth injuries. Most often young athletes are getting overuse injuries—like tendinitis, little league arm, bursitis or patellofemoral pain. The first step in how I treat these injuries is to take out a calendar and write down the game and practice schedule for a year and then start crossing things off. There is also a significant number of ligament tears and muscle tears requiring surgery because kids are playing too much on a fatigued body that can’t catch up to the demands being placed on it.

Another consequence of early specialization is young athletes getting burned out on their sport—quitting at a young age because they no longer enjoy it. When that happens you really have to ask what is the goal of what we are doing in the first place. The pressures of adult financial interests (like club teams) as well as peer pressure and fears of falling behind is something many parents have experienced. Also, kids often love their sport and want to do it as much as possible. Some leagues have artificial age barriers that encourage early specializers as well. All this is to say that the system can be set up against parents and it is difficult to balance those pressures.

Ultimately, that is why a book like Range is so useful. It is a win win idea from health and performance and scheduling to reduce specialization. Less can be more with some activities and variety is useful fo elite performance and skill acquisition.

If you are worried about preventing injuries from youth athletics scheduling a movement screen to make sure kids are moving well before they move often is a good place to start. Treating injuries that do come up early helps limit the damage as well.

Faster, Higher, Stronger Book Review

Faster, Higher, Stronger : The New Science of Creating Superathletes, and How You Can Train Like Them (McClusky, 2014) is an excellent update on where the sports science field is at right now.  He reviews current attempts to “hack” the athlete to achieve optimum performance. Throughout the book the author does a good job of simply communicating complex research.

The book details how innovations in technology—including motion trackers and biometric data—are being used to enhance training. A big part of the puzzle is how athletes training has become ever more personalized—or sport specific—to their given activity. When athletes training is tailored to their distinct tasks (for example a golfer may focus on his torso rotational strength) more efficient gains are made.

Physical therapy wise this book has a lot of good information on how at the high end of performance everything matters.  Biomechanics and analytics become of utmost importance when trying to maximize your abilities. Quantifying limb symmetry, power and functional movement are paramount to maximize the athlete.  It takes higher level analysis and (often) advanced technological equipment to identify any weaknesses or wasted movement that the naked eye can't see, but there are simple gains out there for all athletes.  

While this book is geared towards the elite of the elite athletes there is a lot of practical advice that can improve performance at any level. For instance, what’s easier than sleeping, drinking, and eating?

Faster, Higher Stronger details how sleeping more than 8 hours/day has consistently been shown to confer performance benefits. It has also long been known that caffeine can aid performance—it even used to show up on some lists of banned substances because of its benefits.  About 2 cups of coffee is all most people need—more than that does not give additional performance improvement. A unique property of caffeine is that it has benefits for all types of activities—aerobic and anaerobic or running and strength training. There is also a good analysis of the value of the supplement Creatine which has long been known to benefit strength training.  

If anything, in my experience, novice to intermediate athletes can experience even greater benefits by refining movement patterns and addressing deficits simply because they have easier corrections to make and more room to make gains.

Sport Science offers an advanced return to sport motion analysis of the required movements (such as cutting and jumping) needed to perform almost all sports. It’s a great starting point if you are serious about improving your athletic performance or preventing injury.

Born to Run Book Review

Born to Run (McDougall 2009) is a fascinating book that is often credited with popularizing the barefoot running movement. It tells the story of the Tarahumara tribe specifically their unique running style and footwear. The Tarahumara actually wear a type of shoe—the Huarache sandal—fashioned out of old tires with leather laces that would be closer to a minimal support shoe. Either way it appears to be highly effective at running long distances frequently without injuries.

While the story of the Tarahumara is very compelling. I was very interested in McDougall’s telling of the history of running shoes and running shoe companies as I don’t believe this is very well known. The narrative states that running injuries used to be relatively rare. Running shoes at this time were very basic with minimal cushion and neutral arch support. As the sport became more popular in the 1970’s injury rates began to rise. A note of caution with this story is that the incidence of running injuries wasn’t studied much if at all prior to the this time.

The sport becoming more popular also correlates with new running shoes from new companies such as Nike and Asics beginning to hit the market. Over the following decades, the running shoe market continued to grow with additional companies and innovations becoming popular. These shoes grew increasingly specialized with more cushion and more arch support. Surprisingly with all the money, research and innovation poured into the running shoe arena no shoes have been proven to reduce injuries.

McDougall himself adopts the barefoot running style and tells his story throughout the book. He details his transition from a broken down former runner to a pain free runner by switching to a barefoot style. He also relates the stories of other ultramarathoners who have been successful with this style. It is a very interesting and absorbing read for anyone with an interest in running.

The rise of barefoot running is in part a response to the high frequency of injury rates. Commonly, it is reported that up to 79% of runners per year can expect to hurt themselves. The knee is the most often injured area and there is a significant connection to knee demand and the heel strike running pattern. The purpose of barefoot running is to encourage a forefoot or flat foot strike rather than a heel strike. It also promotes foot/ankle strength by putting more demand on this area of the body.

There are a few caveats to all of this information. Practical Physical Therapy advice is to not switch from a successful style or shoe. If you are a fully cushioned heel striker without injury, I would stick with the style that has worked for you. Biomechanical changes to running form are tricky and the group that benefits the most are those with a history of recurring injuries especially of the knee. One of the biggest problems that novice barefoot or minimal shoe runners have is they switch their shoe but not their running style. That often means they take the cushion away from their heel but still pound on it with every stride which is a recipe for injury.

Most important is to allow a great deal of time to accommodate to a new running style or shoe. A walk to run program with limited mileage will reduce the incidence of injury. The most common injuries seen from switching to a minimal shoe are stress fractures, plantar fasciitis, and achilles tendinitis among others. If you would like to be proactive, I highly recommend talking to a PT to get instruction and technique advice to appropriately strengthen the areas of your body that will be involved with your new running style.

A big problem with the 10% rule

Conventional wisdom say to increase your running mileage 10% a week. If you ran 10 miles last week you can run 11 miles this week. This will keep you safe from injury they say.

A big problem with that idea is that it isn’t based on anything.

An article published in the journal JOSPT (How to Safely Increase Your Mileage) looked into how much you should be increasing mileage each week in order to avoid injuries. The answer was a little more nuanced.

The research found that runners that increased their mileage less than 10% over two weeks had lower rates of injury. Also, that if you increased your mileage more than 30% over two weeks your chance of sustaining an injury was higher.

There are lots of ways to hurt yourself running but increasing mileage too quickly is one of the most common. Good, practical advice is to have an individual running plan tailored to your body’s capabilities and running history.

Looking to get started? Fortunately, this (and much more) is included in a Sport Science running analysis!