So, you’ve torn your ACL. A common injury (unfortunately) amongst female field athletes. Tearing your ACL is every bit painful psychologically as it is physically. It is common to feel helpless and overwhelmed after suffering such an injury. Whilst you cannot untear your ACL, you aren’t powerless to help yourself. I thought I would put together this article to give you an indication of what to expect. Having torn my ACL twice, and had three surgeries, I feel I have a wealth of experience on the subject, and I wish I had something like this to help me when I was going for surgery.

This series will be split into several parts; pre-operative preparation, the operation itself and the post-operative care.

The Role of the ACL: What Is It?

The anterior cruciate ligament (ACL) is a ligament that connects your femur (thigh bone) to your tibia (shinbone). The ACL serves to resist anterior tibial translation and rotational loads[1]. (Translation: it’s what stops your knee from sliding forward over your toes and resists twisting forces). It has a complex collagen and elastic fibre structure, which enables it to endure strains and stresses. Until you tear it.

Unfortunately, females athletes are far more predisposed to ACL injuries than men. Particularly if you are participating in a sport that involves you pivoting, jumping or suddenly slowing down. Any sport that involves the knee being loaded seems to pose a higher risk to females for ACL tears [2].

As Drake once said “If you’re reading this, it’s too late”, and if you have happened upon this article you have likely already suffered an injury. So, we won’t waste too much time discussing how it has happened to you. This has happened, so now it’s time to deal with it.

Depending on the severity of your injury, your age and your intention to return to activities, your orthopaedic surgeon may refer you for surgery to repair the ligament. This is when it starts to feel overwhelming, and all the more real. Your surgeon may decide to use a tendon from your patella (knee cap) or your hamstring (back of your thigh). Research has stated that the patellar tendon reconstruction has a lower failure rate[3]. This is a perfect example of how the literature must always be taken with a pinch of salt. You might be reading this thinking: “mother of God, I’m going for a hamstring tendon graft, I’m finished. Are Westlife still singing at funerals?” I would encourage you to relax. The observed difference in failure rates was very small, and failure rates were low in both groups. Furthermore, if your consultant recommended a certain type of graft for you, it is because they think it is the best fit for you. Would you rather the surgeon perform their 100th hamstring tendon graft replacement or their 20th patellar tendon replacement on you?

Preparation for Surgery: The Holy Trinity

If you’ve elected for a reconstruction, your preparation for surgery is threefold:

1. Nutrition

2. Exercise/Pre-Operative Strengthening Exercises

3. Mindset

The Holy Trinity of setting yourself up for successful recovery is obviously unique to the individual, but I will share some of my experiences with each of the categories, to give you an idea of what I mean.

Nutrition

I think this part of pre-operative planning is hugely overlooked amongst athletes. For many smaller scale (read: not county) athletes, you can feel left on your own and without any guidance. I know the first time I tore my ACL (2015), I felt that I had no idea what I was doing, completely on my own. But what is always there? Food. Sweet, sweet hyperpalatable goodness. Furthermore, I didn’t put any work into ensuring I had the right mindset going into this, and so my main concern was that I would get super fat now that I couldn’t exercise as much as I did.

In preparation for surgery, I would argue that you shouldn’t be in a calorie deficit. I don’t think it will benefit you to be starting your recovery already in a catabolic state, however small. Individuals may benefit from sitting at maintenance calories at the bare minimum. The focus should be on establishing sufficient protein intake, and keeping it as high as possible, to prepare yourself for recovery.

Before I had my most recent surgery, I spent a good six months in a calorie surplus, ensuring my protein intake was high. As a result, I was comfortable at a higher body fat percentage/weight already. And spoiler alert, it didn’t kill me! Furthermore, I was able to establish an adequate protein intake and ensure I had all my nutritional ducks in a row so to speak.

If you are unsure as to how to set this up properly, I would highly recommend doing some research online, or working with a nutrition coach. Food is a central part of all our lives, and it has the potential to take over space in your emotional well-being if you aren’t careful. Give yourself the best possible chance at recovery.

Exercise/Pre-Operative Strengthening Exercises

Depending on your injury, your capacity for exercise may be limited. I would strongly advise following the recommendations of your physiotherapist or doctor. I know myself, before my most recent surgery, they advised me to avoid running or high-impact exercise. Anything that was painful or stressed my knee joint was a big no-no.

When you immediately get the list of what you “can’t” do, it has the tendency to get inside your head. You run the risk of only focussing on what you can’t do. And yes, don’t get me wrong, it is SHITE that you can’t train how you used to. But you aren’t powerless. I used this time to focus on building muscle, and gaining strength in the gym. You can also use this time to improve your mobility, so that when you finally get that shiny new ACL, you are in the best position to move it.

I don’t want to dwell too much on this section, as I plan on writing a second article dedicated to setting up your ACL strengthening programme.

Mindset

This is the biggest hurdle you will face, particularly if it is your first major injury, and you’re looking at an extended time away from your sport of choice. There is no point in me telling you it’s all sunshine and rainbows, and if you read a few inspirational quotes it’ll all be grand. Because that’s a load of shit. There will be down days. You will feel like you have made a terrible mistake, and that it’ll hurt forever. You have to accept that these days will come. That doesn’t necessarily make it any easier to take, and it is a super frustrating time for you. But it’s not forever.

I would say this is where you need to do the most work pre-operatively. Get yourself into good practices, such as journaling or reading good books and podcasts. Get used to being comfortable in your own head, as you will be spending a lot of time there post-operatively. It can be worth writing down all your thoughts and worries, and this can help you work through the issues yourself. It can also be nice to look back and see how far you’ve come. There is also no shame in reaching out and talking to someone if it is really getting you down. As the good saying goes: you only have one head.

Suggested reading:

  • The Obstacle is the Way, Ryan Holiday
  • The Daily Stoic, Ryan Holiday (can you see the theme here?)
  • Antifragile, Nassim Nicholas Taleb
  • Man’s Search For Meaning, Viktor E. Frankl

Conclusion

In conclusion, tearing your ACL is not a fun time. It can be a huge mental challenge, in addition to the physical hurdles you will face. You are not powerless however, and in this series of articles, I will help you prepare for the hurdles I have faced, and how you can overcome them yourself.

“The obstacle in the path, becomes the path. Within every obstacle is an opportunity to improve our condition.”

Ryan Holiday, The Obstacle is the Way

References

  1. Duthon, V.B., Barea, C., Abrassart, S., Fasel, J.H., Fritschy, D., Ménétrey, J. (2006) ‘Anatomy of the anterior cruciate ligament’, Knee Surgery Sports Traumatology Arthroscopy. Available at: https://pubmed.ncbi.nlm.nih.gov/16235056/.

2. Hewett, T.E., Myer, G.D., Ford, K.R., Heidt, R.S., Colosimo, A.J., (2005) ‘Biomechanical Measures of Neuromuscular Control and Valgus Loading of the Knee Predict Anterior Cruciate Ligament Injury Risk in Female Athletes’, The American Journal of Sports Medicine. Available at:  https://engagedscholarship.csuohio.edu/cgi/viewcontent.cgi?article=1195&context=enme_facpub.

3. Samulsen, B.T., Webster, K.E., Johnson, N.R., Hewett, T.E., Krych, A.J. (2017) ‘Hamstring Autograft versus Patellar Tendon Autograft for ACL Reconstruction: Is There a Difference in Graft Failure Rate? A Meta-analysis of 47,613 Patients’, Clinical Orthopaedic Relations. Available at: https://pubmed.ncbi.nlm.nih.gov/28205075/.

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