Sidelined by an ACL Injury?

Return to sports with confidence, thanks to a new collaboration

Knee Pain, Woman Holding Sore And Painful LegAnterior cruciate ligament (ACL) injuries can be devastating for an athlete, especially a young one. As recent decades have passed, we’ve gained ever more knowledge regarding graft selection, and surgical techniques have improved our surgical efficiency and objective results in patients undergoing ACL reconstruction. Despite these improvements, in the youngest and most active patients who play a sport and wish to return to that sport, subsequent injury to the reconstructed knee — in addition to the opposite knee — is a real risk and approaches 25% in combination. Our challenge as fellowship-trained orthopaedic sports medicine surgeons is to give patients the best chance at the best possible outcomes by being judicious about graft selection, patient expectations and optimizing postoperative rehabilitation.

Returning to the field or court with confidence can be challenging for young athletes after ACL reconstruction. It takes a collaborative effort of the whole sports medicine team — the doctor, the physical therapists, athletic trainers, and strength and conditioning coaches. In the past, time from surgery and some basic strength tests were used to tell the patient when they could return to the activities they enjoy. Research has shown that the biology of the healing ACL graft can take two years to complete, and that the closer the patient progresses toward 12 months post-surgery, the lower the risk of reinjuring the graft, or even the ACL in the other knee. There has been a shift in philosophy from a strictly time-based approach to using a combination of time and  physical and psychological criteria to form return-to-play programs (RTP).

Most patients do not have enough covered physical therapy to take them as far as we need to take them to clear them to return to play. RTP programs were created to allow further supervision of the recovering athlete. The idea is to help guide them through the late stages (6-12 months) of ACL recovery to increase the confidence level of the physicians, trainers and the athlete when it comes time to hit the field again.

A collaboration between the sports medicine fellowship-trained surgeons at the New Hampshire Orthopaedic Center, Apple Therapy and TOP Fitness has created PROS (post-rehab orthopaedic services). This will be a formal, RTP program for late-stage ACL reconstructed patients who wish to take advantage of the supervision of a trained professional to continue to monitor and correct deficits, helping them to prepare for a safe return to playing.

The evaluation and testing tools that are at their disposal will allow for some objective data to be obtained to help the whole care team, giving them increased confidence in tailoring recommendations as sports are reintroduced. Some of these include Functional Movement Screen (FMS), Y balance, strength measurements and ratios, Vail Tests (video), and the revolutionary dorsaVi movement and muscle sensor technology (

The New Hampshire Orthopaedic Center is the cornerstone of a self-contained orthopaedic surgical care center where you can find all the services you need from start to finish. It begins with a visit with your orthopaedic provider at NHOC, and may be followed by advanced MRI imaging at Four Seasons Imaging (FSI), surgery at the Nashua and Bedford Ambulatory Surgical Centers, and postoperative PT at Apple Therapy Services.

To completely close the loop for our young athletes with ACL injuries, we’ll now be able to provide this valuable late-stage ACL RTP program. Patients should no longer feel the need to seek care south in Boston, as all of our sports medicine physicians are fellowship trained at some of the most prestigious fellowships in the country, and their surgical expertise is now combined with top-tier, state-of-the-art imaging, rehab and a post-rehab RTP program. Nothing is absolute, and although we may never reach a 0% reinjury rate, with this added supervised RTP program, we can obtain objective data beyond the trained “eye test” to optimize our confidence levels, and that will go a long way toward an athlete’s physical and psychological preparedness.

Take-away Facts and Figures

Apple Therapy Manchester, in partnership with Top Fitness in Nashua and New Hampshire Orthopedic Center (NHOC), is now offering a post-physical therapy strength and conditioning program for athletes in the late stages of rehabilitation following ACL reconstruction.


The Y-Balance test, in use here, is a simple way to
measure a person’s motor control and demonstrate
functional symmetry of the lower extremity in three planes of motion. Photo courtesy New Hampshire Orthopedic Center

The Data:

  • Only 13.9% of athletes met criteria to return to sport.
  • 80% of athletes did not meet strength criteria and 50% met hop test criteria.
  • 66.1% of athletes returned to or exceeded their prior sport activity level after ALCR at one year and after return to play clearance. However, if athletes met and passed both strength and hop test criteria, 81.3% were able to maintain their prior level of sport participation at one year after being cleared to play, reports Joe Nance, P.T., M.P.T., O.C.S., C.O.M.T., F.A.A.O.M.P.T., A.T.C.
  • Simple decision rules made in the rehabilitation process can reduce reinjury by 84% after ACL reconstruction.
  • Delaying a return to sport until 9-12 months post-ACL reconstruction gives the athlete more time to meet strength and quadriceps growth criteria.
  • According to the Delaware-Oslo Cohort Study, every month that return to sport was delayed, until nine months after ACL reconstruction, the rate of reinjury was reduced by 51%.

The Program:
An optional “bridge” program after physical therapy falls under the P.R.O.S. name (post rehabilitation orthopedic services).

  • Custom tailored to the individual patient
  • Identifies and addresses residual deficits/limitations with testing
  • Works to correct said deficits to improve physical and psychological condition and outlook
  • Can begin 3-6 months (1 on 1) or 6-9 months (small group) post reconstruction



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