All Things ACL: Finding the Silver Linings...

A Google search on "ACL tears" show a lot of results that are, at best, intimidating to read through. It's been a while since I dove into the latest knee injury research, but I find myself going back into it again recently. 

ACL tears have a stigma to be "career-ending". In the case of martial artists, this can range from retirement from competition, or a complete discontinuation of practice. I'll share my personal feelings about this toward the end, but I realize that life happens, and it's perfectly OK to want a change unapologetically.

Here are some ACL tear statistics in hope of providing educational value and a quick reference. I hope you find this helpful, either for yourself or in supporting your student through the rehab process.

The Statistics...

Nature of ACL Injury

• ACL injuries may occur due to a non-contact event (70%), direct contact event (30%), or indirect contact event. However, I'm not quite sure what it means to have an "indirect contact event". 
• ACL injuries commonly involved some sort of acceleration and/or deceleration activity, with excessive knee valgus and (most commonly) tibial external rotation. However, there is a study that suggests that tibial internal rotation during valgus places more load on the ACL than external rotation.
• ACL injuries commonly do not occur in isolation. Meniscal tears, other ligament tears (i.e. MCL), or other orthopedic findings are likely.

Sources:
www.physio-pedia.com/Anterior_Cruciate_Ligament_(ACL)_Injury
www.ncbi.nlm.nih.gov/pmc/articles/PMC2474820/

Physiological Impacts to Likelihood of ACL Injury

• Women are more likely to experience an ACL tear than men. The consensus generally agrees that it is between 2x to 10x more likely for women. 
• Physiological mechanisms to ACL injury other than the positional knee valgus include ligament dominance, quadriceps dominance, leg dominance, and trunk dominance. In short, there's an overuse of one strategy in absorbing load, and forces are not equally distributed appropriately throughout the body.
• Fatigue and stress impact overall performance and the body's ability to mitigate risks to injury.

Sources:
www.yalemedicine.org/stories/sports-injuries-gender/
www.beaconortho.com/blog/risk-acl-injuries-female-athletes/
www.ncbi.nlm.nih.gov/pmc/articles/PMC4805849/
www.ncbi.nlm.nih.gov/pmc/articles/PMC3096145/
corporate.dukehealth.org/news/study-shows-men-and-women-tear-acl-same-way-non-contact-injury
​​

What Happens After Treatment of Choice

• "Despite advances in ACL reconstruction techniques and the use of early rehabilitation principles such as immediate knee motion and quadriceps strengthening exercises, some recent studies have reported high failure rates when patients resume athletics after surgery." 
• ​Within the first 2 years after ACL reconstruction, there's a high rate of re-injury due to a non-contact event, either on the ACL graft or on the non-surgical knee.
• This post-reconstruction rate of injury on the non-surgical knee is approximately 20%, while the rate of injury on the ACL graft is approximately 9%.
• There is a wide variability in the rate of a second ACL tear, anywhere from 6% to 31%.
• Poor outcomes were seen in athletes under 25 years of age when an allograft was selected for the primary ACL reconstruction.
• It can take up to 2 years for the ACL graft to fully vascularize. I can't find the specific source from my physical therapy days, but there is a study suggesting that blood flow rate is the highest right after ACL reconstruction (to promote healing) but then decreases due to the negative feedback loop. This decrease in blood flow usually coincides with the time an athlete begins to return to training, between 6 to 12 months.

Sources:
sportsmetrics.org/published-rates-of-reinjury-after-acl-reconstruction-show-need-for-advanced-neuromuscular-retraining/
www.ncbi.nlm.nih.gov/pmc/articles/PMC4641548/ 
blog.summit-education.com/physical-therapy/3-key-factors-to-developing-a-successful-acl-rehabilitation-program/ 

What do these all mean for me, the practitioner?

"Now is the time to really think about your career in ___________, and take care of yourself."

Yes, that was said to me. Just fill in the blank with "Dang Soo Do", and it was practically word-for-word.

And I hated hearing that advice. In a culture where being busy and actively in pursuit of something is rewarded, sitting back in reflection is not generally accepted. In my naïveté, this downtime wasn't OK and I took the advice as something insensitive back then. 

I've certainly learned many years later, and have a better understanding of what I wanted out of my life and my Dang Soo Do practice. 

Take this time to rebuild your physical and mental foundations. Learn how to be comfortable with the unknown and the non-linear path. And take some time to just reflect: Don't do anything rash. Stand firm like a tree and sway with the wind. And remember, you are not what you do, and it is perfectly OK to change your mind.

What do these all mean to me, the instructor / coach?

"What can I do for you?"

This is not the time to not know how to act or feel around your student. This is where you shine as an instructor or coach, and use your creative outlet to ensure that your student continues to feel as involved in your community. 

Offer opportunities for your student to train with you privately and at the student's pace in coordination with medical recommendations. Outline a return-to-training schedule, even if it means exploring just basic techniques and hyung for up to a year. Offer opportunities for your student to safely mentor other students, or to support leadership activities. Offer a safe environment for your student to return to while still providing challenging, non-contact drills. 

I highly recommend making an agreement with your student to withhold free sparring activities for a minimum of 2 years. There is a lot of neurological stimulus when it comes to free sparring, and it may lead to loads that exceed physiological demand due to the gap of active training. Encourage your student that this gap is temporary and that it is important to rebuild martial foundations without any expectations or preconceived notions from pre-injury. Show them what it means to have a white belt mind and spirit, and lead by example.

What did these all mean for me?

This was a very difficult time for me. I was passionate about returning to where I was before the injury, and it fueled a lot of my motivation to achieve many rehab milestones early. 

Things didn't really hit me until 3 months after surgery. By this time, I was isolated from my martial arts community. I returned to work to learn that I was dropped from projects where I contributed before the injury, and worse, was not recognized in those efforts. My upward career mobility stalled. Returning to my martial arts community after each difficult work week suddenly became a game of appearances, where I started play the part of having resilience and grit, but in reality, I felt lonely. I couldn't move well, and worse, I didn't feel safe training because I didn't know how to confidently ask for something different than what was normally offered.

My feelings of helplessness amplified to other areas of my life. I eventually stopped training. I became really unhappy with my career. I stopped complying with my home exercise program which delayed my "graduation" and discharge from physical therapy. And while I'm not proud to admit it, I became really difficult to live with at home.

Then I found my silver linings. Many years before, I made myself a promise that if and when my livelihood becomes endangered due to my recreational competitive hobby, that I would stop. I shared this decision early, even before my surgery, and I was met with much displeasure from my instructors. Truthfully though, it was the writing on the proverbial wall after many undesirable experiences in the tournament circuit. Once I made that decision, I started to ask the questions of how do I continue training in martial arts without the goals toward competitions. I started to dive deeper into the scientific evidence of ACL injuries, inadvertently increasing my knowledge on what it takes to mitigate risks of a re-tear and what it takes to properly rehab. It also led me to try and understand why the martial arts curriculum was designed in a particular order, and if the curriculum was used in its original intention to better prepare and transition the body for higher demands of performance. And then I found a method that provided me the means to return to martial arts training as safely as possible given my mobility restrictions. 

So what finally worked for me?

Basics. Biomechanics. Balance. Life.
I started studying privately (and remotely). My teacher and I agreed on a curriculum strategy and to essentially "start over". I abandoned my preconceived notions of what my black belt rank meant to me, and in a way took solace in thinking that I deserved no higher than a white belt.

I changed my rehab programming, and took a chance on an extremely scaled version of Crossfit. I changed my career trajectory, pursuing an option to work from home full time in order to dedicate most of my availability to redesigning what my day to day looks like in pursuit of a "healthier" me. 

I pursued additional education in areas related to martial arts and mobility. 

I prioritized the needs of my immediate family. I grew up in a family culture of prioritizing external achievements, but never thought about my internal achievements and work efforts as a wife, home manager, and pet parent. It may sound silly to even mention this as "family comes first", but it wasn't something I reflected upon to make sure that I rated my efforts on a daily basis.

I disappointed a lot of people for making unexpected decisions, and as a result, I even questioned myself. But in the process, I learned to challenge my default mindsets to become unapologetic with my choices. This newly-gained skill gave me the chance to examine my state of balance - physically, emotionally, and mentally - against a world driven by the proverbial hamster wheel.