Over the last several years, the PT community has grown more convinced that athletes should not return to sport earlier than nine months.
Research reports suggested that 9 months was a magic number. But what if your patient looks amazing at 8 months?
In this episode, we review a recent article that showed that athletes returning earlier than 9 months were not at more risk if they met the proper objective criteria.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 364: Is 9 Months the Sweet Spot After ACL Reconstruction?
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Show Notes
Transcript
Mike Reinold:
Welcome back, everybody to the latest episode of the Ask Mike Reinold Show. We’re here at Champion PT and Performance for another podcast episode with the new format that we started last episode. Check out our last episode if you didn’t yet. But what we’re going to try to do is we’re experimenting with the concept of a journal article review. We’re just going to go over a recent article that we want to hear our clinical interpretations and what we’re going to do different based on these articles. So, not like an hour-long review of an article where we go over everything in detail, but just a quick hit where you can read the article, but you’re already kind of getting our snapshot of what we thought, what we’re going to do different based on it. So anyway, I’m here again, Lenny Macrina, Kevin Coughlin, Dave Tilley, Lisa Lowe, Anthony Videtto, Dan Pope.
We’re here today. We have an article from British Journal of Sports Medicine from 2025. It’s pretty current, but this just came out and was kind of hitting the social media buzz a little bit here. But essentially, a study out of Aspetar in Qatar that essentially talks about: is nine months the sweet spot for male athletes to return to sports after ACL reconstruction? And man, I’ve been waiting for this article. I’ll just leave it at that. But essentially, what they did is they looked at this article over time. In total, I think they had, let’s see, 379 athletes that returned to pivoting sports, some more kind of field-based sports, two years after ACL. And what they wanted to do is essentially just look at their outcomes, and one of the things that they looked at was time to return to sport, and based around that nine-month strategy, but was time correlated to the success of the outcome.
So, I thought this was a really good study. I like studies like this that I think are just good studies in general, but great introductions and discussions that have some clinical implications in them. That’s why British Journal of Sports Medicine always does a good job, but who wants to start? What do they think? Any thoughts on this article? Who wants to jump in first?
Dave Tilley:
Yeah, so this is actually fresh in mind. I’ve been thinking about this a lot before this article because I have three ACLs and one tibial plateau fracture that are all high level athletes and are going through the early to mid post-op phases. And I think the two big takeaways that I had, that I think maybe will springboard the discussion, is… So one is we are constantly dealing with biologically cleared versus functionally cleared with a lot of this stuff, knee meniscus, tibial plateau. And I have two examples that are fresh in mind when I was reading this. I have one soccer player, high level. It’s her second ACL, other side, and at three months, more or less, she had a 12-minute appointment where they said, “You’re doing good. Good job, start running.” And I was just like, “Okay, that’s aggressive.” And her doctor was like, “Yeah, it looks great. Motion’s good. You don’t have any pain, sounds great, let’s get you running and get you in a program.”
No LSI, no strength testing, no nothing. And she was like, “I don’t feel ready to run at all.” And her LSI was good. It was at 80%, and then we retested. She got stronger, so it’s 75, but just the bigger picture is just like, “All right, three months, run.” And then the other example is I have a gymnast who had a tibial plateau growth plate fracture, and at six weeks, she saw her surgeon. It was a non-op case, but more or less he said, “You’re good to go. Slowly ease back into gymnastics.” And then we had her run, and she just limped like crazy, and she has a 60% LSI. Her quad is just weak from eight weeks of not doing anything. And in my mind, it just brought up the bigger picture, which is how are we dictating why you’re ready to go if it’s just like, “Okay, you’re biologically cleared,” but clearly these two are not functionally ready to do that.
So, I think this article at the nine-month mark looked, very similarly, about why is “nine months we’re good to go”? What if we don’t have any good objective measures of strength, power, and that? Which leads to the second point, which is what Mike and I talked about with the 10/80 in services for Octavia, or sorry, for the soccer player who’s with ACL. She’s a cutting and pivoting sport. So yes, vault measurements or jump testing is great, LSI is great. We’ll use all those measurements, but I care more about her symmetry with deceleration, cutting versus pivoting on the 10/80, and her power output, whereas the other person, who’s a gymnast, is a vertical-based sport. I maybe lean a little bit more onto the single leg depth drop measurement. She has a long-term for eccentric overload. So yes, we’ll measure all of them, but it’s leading the article, which is we need a big picture test, and then what is the specific thing that that sport needs? Can we measure more in a niche bucket of cutting, pivoting, change of direction, versus vertical force displacement?
Mike Reinold:
I love it. And just the different types of objective testing that we can do, and how I think we’ve seen it. You talked about that one person. What’d you say? It was three months, and they said, “Hey, it’s three months you can start running.” I mean, we even see the same thing: “Hey, it’s nine months, you can now return to sport because it’s nine months.”
Lenny Macrina:
Six months. We’re still getting six months from doctors.
Mike Reinold:
Right, which sometimes that’s weird too. I actually had a conversation with a well-known orthopedic surgeon who is elsewhere in the country, just a well-known person. I was talking in a meeting, he was telling me a story on how he had an athlete, high school kid, that was just doing amazing. He was knocking everything out of the charts and he let him return to sport at eight months, and then the kid ended up re-hurting his knee. He tore his ACL again, and the dad’s going crazy because he Googled it and he found this magic nine-month mark that the researchers, not the clinicians, have kind of come up with this magic number a little bit. And the father’s upset, and the guy’s like, “No, your son looked amazing.” He’s like, “This nine-month thing is kind of interesting.” But why don’t we start back over and maybe, I hate to pigeonhole Lenny on this here, but the historian, Lenny Macrina, where does nine months come from?
Lenny Macrina:
Yeah, there was the Grindham paper, which they cite in the article, that says for every month you wait after six months, you decrease your retear rates by a certain percentage. So I mean, I get that paper was the landmark in that it woke us up to six months is not the sweet spot, that it should be longer, but longer is not necessarily nine months. That was the sweet spot from that article a few years ago. So this article… I think it’s appropriate in that it tells us you need to test, and you need to test appropriately. And if you look at their protocol that in the discussion section, I think it was under methodological considerations, they have a whole… If you click on the link, there’s a whole bunch of stuff they talk about, which is counter movement, jump testing, isokinetic quad testing, jumping biomechanics, which gets a little weird because they just talk about normalizing absolute and symmetry values from moments, angles, and work.
Who can do all that stuff? Unless you have something fancy. But I think it’s just more testing, meaning we need to make sure that they can jump symmetrically, they can receive both concentric and eccentric impulses that you can measure on force plates. Fortunately, we have that. A lot of people don’t. I think that’s the issue, is we need more testing, and if you’re a facility that doesn’t have this stuff, you need to befriend facilities that you trust that do and have them test for you because I think getting appropriate testing… We don’t have to paralysis-by-analysis the patient, but I think you need more testing. Isokinetics would be great, or some kind of isometric like we do, and getting them tested and using a 10/80 to look at their forced production side to side while they’re doing certain movements. I think that’s all critical, and that’s what this paper said.
I think one other thing that the paper said, and as a bone-patellar tendon-bone guy, they did admit that the patella tendon grafts did do better than the hamstring grafts, but the majority of the surgeries were done on hamstrings, where you use hamstring grafts, but the professional athletes got the bone-patellar tendon-bone grafts. So it makes you wonder…
Mike Reinold:
That’s interesting.
Lenny Macrina:
Why are we still doing all this? Why are we still messing?
Mike Reinold:
That’s interesting.
Lenny Macrina:
And it was a study of only males because the location of the research study was in a country that I don’t think… How can I word this? Females are not necessarily invited to play sports.
Mike Reinold:
I think they say that in the paper, so you’re fine. You’re just quoting the paper.
Lenny Macrina:
There’s a DEI section in the paper that talks about that. I’m not just winging this. And like you said, it was mainly soccer players, cutting, pivoting sports. So good. I think in our male athletes who have either a hamstring or a bone-patellar tendon-bone graft, you need to test them. You need to test them. That nine months is not the cut-off. I have kids right now that I’ve gotten back earlier than nine months, and I have kids that could get back earlier than nine months, and it’s in my head, but I need to test them appropriately and make sure that they’re comfortable. And then when I’m done testing them, they still need to get on a field in practice, in a non-contact situation, and then in a contact situation, and then at a hundred percent effort where they’re practicing and taking bumps and bouncing off of people, whatever sport they’re playing. And then they go back to play, and that’s probably another month process as well. So getting all this in-house testing done does not mean that they’re going back to play their sport.
Mike Reinold:
Yeah. Looking at the numbers too, real quick, Len. So average time return to sport for competitive athletes was 9.9 months.
Lenny Macrina:
Right.
Mike Reinold:
The average time, so keep that in mind, but the range was 5.2 to 23.8. That’s crazy, by the way. What on earth takes two years? But anyway, that’s another conversation. But 5.2 and then with the hamstring graphs, right? It’s in the recreational athletes, it was 6.7 to 19.6. So again, 6.7. There’s a good amount of people here that returned before nine months, and they did not show any correlation between outcomes if you return before nine months. And the earliest was 5.2, and I think that would freak a lot of people out on social media, especially the inexperienced clinicians that are just regurgitating what the researchers are saying, not the clinicians… That they’re saying nine’s a magic number and that sort of stuff. But Lisa, what are you thinking?
Lisa Lowe:
So more from your guys’ experience, since we have so many ACLs in-house right now, if you have an athlete who’s progressing along that you feel like is showing that they’re passing all of the testing really strongly, whether it’s strength testing, jump testing, all of the things all together, I guess, my question is, what level of doing all the things is good enough for you to consider a significantly before nine months clearing moment? To me, they would need to ace every single thing absolutely perfectly if I was going to let them go back to something before this, for better or worse, general accepted timeframe. If you’re going to clear them for six months, they better be perfect. I know you’re always… Lenny’s watching every single everything of what people are doing when they’re in-house, and same with everybody else. What are the things that you’re… Do you let them have anything that’s even the teeniest bit compromised, or do they have to literally ace everything absolutely perfectly?
Lenny Macrina:
Yeah, I don’t want to be the reason why they retear if I make a decision. So they better be perfect, and it better be a perfect situation, and the doctor better be on board, and I have convinced the surgeon and the family and the athlete, if I’m dealing with a high school kid, the family’s involved, that this is the right decision. It’s a senior year, we’re trying to get that one game into play, spring lacrosse, this better be a perfect situation. I just had somebody come back to play college lacrosse a little earlier than nine months and we pulled it off. It was roughly around nine months, but she busted her butt to get there. You don’t understand what we had to do to get her ready to play Division 1 college lacrosse. And so there’s a lot of work that goes in, but you better have the testing. You better have the data to back it up.
You better have the videos that you’ve taken, slow-mo videos and acceleration videos, and anything you can get to assess this and make the right decision for this person because again, it’s fun to get them back early and then they get to play their senior year or whatever in whatever sport they play, but if they tear their ACL, the integrity of the knee long-term is shot. Even worse, you have another year of rehab, the mental anguish that goes on. I do not want to be the reason why they’re going to go through that. So I’m very, very, very careful in allowing something like that to happen. Very rare.
Mike Reinold:
We talk about this a good amount here, too. I think there’s a big difference between high school and a collegiate and a professional athlete at a higher level too. It’s probably going to take most high school athletes nine months to get back because they probably didn’t look great going into the injury and the surgery. So the first three months of damage control and stuff, and then you got six months to get them in tip-top shape. Yeah, I bet it takes that long in a high school kid. But what about a professional NFL running back?
We know tons of people at high levels that have gone back. Four is a little early, but we know some… But the four to six month mark with those, and it’s funny, Lenny and I are sitting at an ICA Society meeting and we had this debate. All the PTs that work with high level athletes were saying nine months is crazy. I mean, if it takes nine months, sure, but you shouldn’t have to be nine months. And the researchers, one in particular, were saying “I’d wait two years because the more you can wait, the better.” But it’s a little bit different between that group.
Dave Tilley:
A million dollars for that person.
Mike Reinold:
But I mean, if you’re Adrian Peterson, not to call you out, Adrian, sorry, but he came back really fast, but he was also in amazing shape going into the surgery. So this is where again, time’s kind of crazy. Kevin and I were talking about this in the clinic the other day, but again, younger clinicians all the time will be the first to tell you, after looking at this, like, “Oh, if you come back before nine months, it’s absurd. That’s not what the research shows. That’s crazy.” Then they’ll also be the ones that tell you, it’s like, “Ah, I don’t follow protocols. I go by feel.”
You’re like, “Well, wait a minute. So you don’t follow the minimum guidelines, but you follow the maximum guidelines?” Sometimes it doesn’t make sense. It’s like this indirect kind of change between those two. So I don’t know. Let me throw this at you guys, although I still want to hear some thoughts, but if somebody’s at eight months and they look perfect, amazing, best you’ve ever had, would you be scared to let them go back? Would anybody? Would anybody say no because it’s nine months? What do you think, Dan?
Dan Pope:
I don’t know. I’ve been burned by this in the past and I think we all know that no matter how good a job we do with ACL rehab, some folks are going to retear. I’ve had… When I worked in Colorado, we had very aggressive physicians that wanted folks to get back fast, like four to six months. And I had some patients that looked great and they still retore when they came back. So I think we see that. I think at the end of the day, we probably just have to educate the patient about what we know and let them make the decision. I think the other thing where we get burned a lot as physical therapists, is I had to go back and look to see how many individuals were in the nine-month paper, and I think there was a hundred athletes, and in this paper we’re talking about was 500.
And it’s not like we’re looking at thousands and thousands and thousands of athletes and seeing if there’s a difference. I think what we see frequently is you see a smaller, underpowered study says one thing. Everyone’s like, “Oh, we definitely need to use this test or not use this test.” Then another study comes out that shows the opposite, and we kind of hang our hat on every study that comes out that’s newer, that’s not necessarily better. I think at the end of the day, as more research comes out, we’ll get some more answers, but it just shows me that we don’t fully have the answer to this question yet. As more research comes out, maybe that gets a little bit better, but I still wouldn’t feel super comfortable sending someone back at eight.
But I would just tell the patient, like, “Look, you look awesome. We have research to show that your risk is probably not going to be a lot different if you look at this paper, but if you look at the other paper, maybe it is different.” So as long as they have that research, they can make that decision. But the other piece is that we see so many folks at the nine-month mark that still look horrible, and that probably means they still have more work to do, and that makes sense.
Mike Reinold:
Yeah, I mean, for sure. Again, remember that range was huge. So again, if you look at statistical modeling, you find out that nine months or every month you wait, you have a lower chance of re-injury. It’s like, of course. I mean, that makes perfect sense. You kind of get that going. But I think what I’m excited about with this article is that we need to get away from arbitrary numbers, just like anything else. Arbitrary numbers are not in the best interest of anybody. I think we would all agree that we’ve had patients at 10 months that didn’t look ready. And again, if you say, “Well, it’s over nine months, you can go, you hit the magical number…” So an article like this comes out, and I think it gives us that freedom again to use common sense, I think.
Where it’s more quantitative, it is objective data, and people need to look good to return to sport. I think that’s crazy. I was excited for this article to think that we might be getting back to that. But what else? Kev, did you have anything? I know you wanted to jump in. What were your thoughts on the paper?
Kevin Coughlin:
Yeah, I was just going to say that going back to look at that nine-month recommendation study, I think one of the issues with that was that a lot of those patients who were retearing did not pass their return to sport testing. So it was really isolating the time, and it wasn’t considering how many of these people were passing testing. So I think this article definitely offers an argument for return to sport testing. You have to clear that before returning, whether it’s at nine months or eight months, or 12 months. And then I think just a couple of other things related to the paper was like you had said, looking at it, the average return time or average duration of rehab was 9.1 months, and there was a plus or minus 3.8. So some people were taking longer, for sure. Some people may be a little bit faster than that 9.1.
And then also out of the whole study, only 71 athletes returned before nine months. So I don’t think this changes it where we’re saying, “Oh, everyone’s getting back before nine months, you’ll be fine.” I think they had really good testing. I think, kind of similar to what we try to do at Champion, it’s pretty robust in terms of looking at strength, looking at power, looking at running, and cutting. And I think the more you try to cover those things, the better outcomes you’re going to get. And if someone’s smashing it, I know Lenny has a couple guys on his schedule right now that are just… If there’s anyone that’s fitting into these categories, it’s those two guys. Up to this point, they’re just looking really good. So I guess a tougher decision to be made when you get there, but if you’re really crushing it, I think it’s hard to say, “Let’s wait that extra month.”
I do wonder with this being only males and a lot of them higher level athletes, I feel like I’m still going to be pretty cautious with the adolescent female, just where their risk is so much higher. And then it always comes back to how many of them are actually going to be passing all these tests before nine months? I think a large proportion of them won’t be. And then the last thing I’ll finally say is, I know at Champion, we’re building out those return to sport programs specifically with the ACL. And I think Diwesh is trying to write those templates to be about nine and a half to 10 months. I think, in a lot of folks, to get through all of the training, you really want to get through without skipping steps. It’s going to take quite a bit of time anyway.
So I mean, I think like you said, Mike, it opens up the discussion to where in certain cases, people are hitting the tests, we have a good conversation, and it lines up with their sport that starts eight months after surgery. Maybe we can get them back at that timeline. But by and large, I think a lot of folks are still just going to take time. It’s not like people are smashing these tests at seven months, and we’re holding them back for the other two months. I think most of the folks we see at that high school, college level, they’re going to need close to that nine months anyway to hit all that criteria. So I think overall, though, pretty interesting paper and good to discuss.
Mike Reinold:
They state that in the paper. They had a couple of good quotes that I thought were really good, but they state that in the paper. I think the earliest was 5.2 months, and I think they made the statement here that they would be very surprised if anybody met the criteria to return earlier than that. It’s kind of what they said. I thought that was funny, but how about this quote? I love this quote: “Each athlete’s journey is unique, influenced by factors including age, motivation…” We should add gender to that. “…Surgical and rehabilitation complications and adherence.” And one thing I think we learned from this article here is that adherence to the program was huge. That led to better outcomes, adherence to the program.
And then using a criteria-based approach was amazing. That Grindham study, only 25% of people met the return to sport criteria before they were allowed to return to sport. Even just saying that sounds weird. That’s weird. So 75% didn’t meet the criteria, but were allowed to return to sport. So I think this evolution is going to come full circle in a really nice way, where this is going to mandate people that are behind the times with not only their rehabilitation progression that are going too slow, but more importantly, their return to sport testing and that criteria to progress to more phases in that criteria to return from sport. I think that’s going to change dramatically. In those PT clinics that just have people doing three sets of 10 straight leg raises for four months, which hopefully is getting less and less, but they’re out there. Those people will not pass criteria.
So you’re going to see a huge shift, I think. In so many different ways, this is helpful, but this was a much needed paper from my perspective that we needed to get away from arbitrary numbers and talk about objective testing again. So anyway, great job. Great review. Thanks for that. Again, we want to hear your feedback. Do you like hearing us talking about an article like this? Do you want us to go back to questions? Put some comments in these posts on social media to let us know if you like them, send us some DMs, or whatever you do to get in touch with us, but we want to hear and see which way we’re going to go and keep building these out. But we thought this would be a nice fresh take on some of our clinical implications. So anyway, thanks again, appreciate it. Go to Apple Podcasts, Spotify, rate, review, subscribe, make sure you get your notifications and your next episodes, and we will see you on the next episode. Thanks so much.
