The surfing world held their breath as John John’s pained expression threatened bad news. A simple kick-out off the back of a modest-sized wave (well, modest for JJF) was a very unlikely mechanism for injury, but his face told a different story. As the diagnosis came through, John’s fears became reality – a ruptured Anterior Cruciate Ligament (ACL).

Whilst an injury to the ACL is not an uncommon occurrence in contact sports, it is rather rare in surfers. The ligament is one of the major stability structures in the knee, particularly for landing on one leg and changing direction during running, neither of which were involved in John’s injury. After repetitively watching the moment he pulled off the wave, it must be concluded that his ACL was already significantly weakened from previous injury, or it could not have resulted in the diagnosis of a full rupture.

The reason sports-people fear a ruptured ACL so much is due to the lengthy rehabilitation period. Unlike tearing the cartilage in the knee, which would see a surfer back in the water just 12 weeks after surgery, an ACL rehabilitation program takes 9-12 months – a nightmarishly long time to be out of the water for any surfer, let alone a professional.

To understand John John’s road to recovery, let’s have a look at the anatomy of the ACL and the surgical procedure used to reconstruct it.

The surgical procedure (in very basic terms) involves cutting out the injured ACL and drilling 2 holes into the old attachment sites of the ligament (one in the top of the shin bone and the other in the bottom of the thigh bone). To create the new ligament, the surgeon will typically cut the patients hamstring tendon (although the knee cap tendon can also be used), and then secure it into the newly drilled holes with metal screws. The operation generally takes about 1-2 hours and the patient is up and walking (with crutches) the same day.

But that is the very start of the journey, with the hardest part yet to come. JJF is now 3 -months post-surgery and the table below outlines an ACL rehabilitation program, indicating he has over 9 month-12 months recovery in store.

The big question on everyone’s lips is: will John John Florence ever get back to his full surfing ability? If we look at the data on how many professional athletes return to their pre-injury sporting performance, studies suggest approximately 60% make it back to their previous skill-levels. The reasons why an athlete would fail to return to their pre-injury levels are both physical and psychological. It’s one thing for an ACL graft to be able to withstand landing a huge air-reverse, but it’s another to have enough faith in your knee to attempt it in the first place following an injury like this. In the physical domain, I think it’s safe to say that John John, with his freakish surfing talent and natural ability, has a better chance than most at making it back to a level that makes him a world-title contender. Ultimately, I believe it will come down to his psychological state: does he want another title bad enough to attempt manoeuvres that will risk re-injury to his ACL?

Will John John get his wings back? Time will tell. Photo: WSL/Poullenot

Time will tell, but there’s one thing I think most surfers can agree on: we’re all pumped to see the return of JJF on the 2020 WSL tour.

 

Phase 1: Early rehab (0-3 weeks)

Goals

Recommended Program

Criteria to Progress to Next phase (tick when complete)

-       Patient understands timeframes of healing process and rehabilitation process

-       Normal gait pattern

-       Muscle re-education and activation especially in the quadriceps

-       Maintain fitness

-       Get knee straight

-       Settle swelling

 

1.Education on importance of compliance of rehab program

 

2. Ice therapy for pain relief (GameReady in clinic or ice-bath at home)

 

3. Manual therapy and physio treatment to increase range of motion of knee

 

4. Activation and strengthening exercises.

 

5. Gait retraining

 

6.Fitness maintenance:

Gym-based exercises for upper body, bike

 

• Knee straight to 0 degrees

• Knee able to bend 100 degrees

• Little to no swelling

• Quadriceps lag test = 0-5 degrees lag

• Normalised gait

 

 

 

 

Phase 2 – Strength Phase (3-6 weeks)

 

Goals

Recommended Program

Criteria to Progress to Next phase (tick when complete)

Full movement

Normal gait at higher speeds

Regain balance and proprioception

1. Stretching program

2. Reformer pilates based rehabilitation

 

3.Home strengthening program for hip/knee/core

 

4. Stationary bike

 

5. Manual therapy by physiotherapist

 

• No swelling

• Pain free AROM and higher-level gait

• Single leg squat and single leg bridge within 95% of other side

• No pain with activity

• Single calf raise 85% compared to other side

 

 

Phase 3 – Functional Strengthening (6 weeks – 12 weeks)

Goals

Recommended Program

Criteria to Progress to Next phase

• Pain free functional weight-bearing activity

• Single leg strengthening and muscle hypertrophy

 

1.Proprioception/ balance exercises

 

2. Advanced strengthening for lower limb and core

 

3.Continue aerobic training on bike

 

4. Manual therapy by physiotherapist

>95% uninjured leg on:

-       SIngle leg sit-to-stand

-       Single leg bridge

-       Single leg Calf strength

-       Balance

-       Full pain-free ROM

 

Adequate core strength testing

 

Phase 4 – Dynamic rehab (12 weeks – 6 months)

Goals

Recommended Program

Criteria to Progress to Next phase

• Safely increase running and dynamic exercises (hopping/jumping)

• Progress towards 85% running speed/agility by 6 months (in controlled setting)

 

1.Advanced proprioception/ balance exercises

 

2. Advanced strengthening for lower limb and core

 

3.Running rehab program

 

4. Dynamic jumping/hopping program

 

4. Manual therapy by physiotherapist to address alignment/tightness issues

-       85% speed and pain-free with running and agility tests

 

-       85% uninjured leg with hopping/jumping/balance tests (see below)

 

Adequate core strength testing

 

Phase 5 – Sports specific rehab (6 months - 9 months)

NB: Patients under 21 years will continue until 12 months

Goals

Recommended Program

Criteria to Progress to Next phase

• Pain free functional weight-bearing activity

• Single leg strengthening and muscle hypertrophy

 

1.Advanced proprioception/ balance exercises

 

2. Advanced strengthening for lower limb and core

 

3.Continue aerobic activity on bike

 

4. Manual therapy by physiotherapist

-       Return to sport testing as per below

 

-       Full pain-free ROM

-       100% speed and agility with running

-       Passed return to contact where relevant

-       Reaction time testing

-       Core strength testing