Returning Athletes to Sport After ACL Reconstruction: What Are We Missing?


An injury to the anterior cruciate ligament, or ACL, can be debilitating to athletes from all disciplines. This is a serious injury that can ruin your career, and many athletes have a valid fear of this particular sports injury. It is also relatively common in many competitive sports, which only increases the sense of dread that comes with a positive diagnosis. While a certain amount of trepidation is normal, there is often a sense of panic that accompanies the diagnosis of an ACL. Athletes may fear the need for extensive reconstruction of the joint, which involves surgery and extended periods of recovery.

ACL Injury, Dynamic Neuromuscular Rehabilitation

This is an injury with a reputation for keeping athletes away from their sport. After an ACL surgical reconstruction, which is expensive, the athlete may require one or more entire seasons in order to fully recover from the procedure. In addition, the athlete may need to train carefully after the surgery. Even if the patient follows all of the requisite directions for rehabilitation, the injury is often too extensive to allow the athlete to return to playing. This may surprise many in the industry who are aware of the technological breakthroughs around this injury. In fact, the number of athletes who are able to return to their sport is notably low, and this is true even after extensive rehabilitation efforts. Naturally, there is a lingering question in the minds of many athletes around these low numbers. It is a reasonable question because of the advances in rehabilitation technology, surgical improvements and other forms of modern research.

Investigating the Mystery of ACL Recovery

Leading research may provide some useful clues into the low recovery rates of this injury. Besides the fact that the role of qualitative monitoring of patients plays a pivotal role in the outcome, there are other issues that can be addressed directly through the available literature on the subject. For example, the Journal of Bone and Joint Surgery released a widely cited publication in 2015 on the care and management of this particular ligament injury. This paper provides the beginnings of the understanding needed to address fundamental clinical questions about the recovery process. For example, the main injury management techniques were standardized. They include MRI, auto-grafting techniques and tendon reconstruction modalities. I found that this conservative approach does not explain the relatively low rates of full recovery.

Dynamic Neuromuscular Rehabilitation, Prevention Modalities

Based on the available research, I concluded that the best area for focus remains in the mitigation of risk and the development of prevention protocols. Naturally, I will continue to track the literature for additional information on rehabilitation in the future. At the present time, it seems fair to conclude that most conditioning and strengthening exercise have no effect on the prevention of this injury.

The role of impact in female athletes is reserved at the present time for a different topic. The available clues still leave many unanswered questions, so this is the focus of my current research.

Specifically, what are the most pressing measurements to use when evaluating an athlete?
According to Lentz, ACL reconstruction can be measured by the lack of knee effusion, lack of instability events and a minimum score of 93 on a specific scale (Lentz et al, 2012). I will continue to investigate questions of stability, proprioception and confidence in athletes who experience ACL joint reconstruction.


In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup

Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)


Complete tear of rectus femoris
with large hematoma (blood)


Separation of muscle ends due to tear elicited
on dynamic sonography examination

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