Warriors Versus Worriers and Return to Sports

Returning to sports after ACL surgery requires time for the new ligament to mature and get strong. In addition, muscle strength and power and neuromuscular coordination need to be restored. Each of these factors may need at least 9-12 months to be at relatively safe levels. A fourth factor, the psychological readiness to return to sports, can often take longer than the 9- 12 months.

The psychological readiness can be influenced by the other factors. If an athlete feels weak and uncoordinated, they often (but not always) feel like they are not ready from a psychological standpoint to return to competition. How an athlete handles stress can affect their psychological readiness.

Enter the COMT gene, or the Warrior/Worrier gene. The COMT gene provides the code for making the enzyme Catechol-O-Methyl Transferase (COMT). COMT enzyme breaks down the catecholamine neurotransmitter dopamine (along with epinephrine and norepinephrine) in the prefrontal cortex of the brain. Continue Reading Here


ACL injuries are the most common knee ligament injury in athletes.  In cutting and pivoting sports, ACL injuries can account for 64% of knee injuries.  For a safe return to sports, the recommended treatment for the ACL rupture is to reconstruct the ligament to eliminate instability in the joint.  Without the ACL reconstruction (ACLR), the instability of the knee greatly increases the risk of subsequent injury to the menisci and articular cartilage.  The long-term health of the knee joint depends on these structures.

Even with this information, some athletes may elect to not have the ACLR surgery and still continue to play sports.  We at ISMI, and the general sports medicine community, do not advocate this as there is increased risk for continued knee instability and subsequent injury.

Often times, these are athletes who injured the knee just prior to their senior-year season (high school or college).  If the athlete has ACLR surgery just a few months before the season was scheduled to start, the recovery will not be complete until well past the end of the season.  These athletes will typically plan to have surgery at the end of the season, hopefully with minimal damage created during the season. Quite often though, the athlete finds that the knee is too unstable to play, and they elect to stop playing part way through the season.


After ACLR surgery, the return to sports depends on several factors:


  1. Length of time after surgery. The new ligament needs time to mature and allow it time to handle the loads created with sports.  Bone bruises that occur at the time of the injury heal slowly and need time to fully heal. For cutting and pivoting sports, we prefer at least 9 months and ideally closer to 12 months before full return.


  1. Strength in the muscles around the knee and hips. Research shows that if quadricep and hamstring strength deficits are present, the risk of re-injury is increased.  Strength deficits in the knee and hip muscles also contribute to altered mechanics when landing and stopping.


  1. Neuromuscular performance. Hop tests and agility drills can look at stability and coordination.


  1. Psychological readiness for full return. This may be the most important aspect in the return to sports, but perhaps is the most difficult to assess.  Time, strength, neuromuscular performance, and a planned progressive return to sports all contribute to the psychological readiness.


These four factors will be discussed in depth in other sections. Continue Reading Here


How long does it take to get back to full sports participation after ACL-Reconstruction (ACLR) surgery?  Based off the best available data published at this point, the physicians at ISMI believe the general answer is 9 to 12 months for high-risk sports like soccer, basketball, and football.  Although we look at several factors when considering a return to play (muscle strength, neuromuscular function and psychological readiness), time is the primary limiting factor. Continue Reading Here

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