TEN STEPS BACK
The Cost of the Comeback Amid Rising ACL Injuries
THE INJURY
“Ten steps back.” One moment, one injury capable of affecting an athlete’s career forever: an ACL tear.
The body has two ACLs, one in each knee. Located between the thigh bone (femur) and shin bone (tibia), the ACL plays a crucial role in stabilizing the knee joint. One of the most common injuries in sports, an ACL tear can occur through either contact or non-contact areas of play. When an ACL tear occurs, it causes instability, pain, and a major pause followed by a long road to recovery for an athlete.
Many athletes experience what is known as the “five stages of grief” when trying to recover and return to their sport, whether that is in high school, at the collegiate level, or professionally. A 2024 study published in Bone & Joint Open found that “ACL injuries are among the most common and debilitating knee injuries in professional athletes, with an incidence in females up to eight times higher than their male counterparts.” Each year, more than 250,000 ACL injuries occur throughout the United States, with more than 100,000 ACL reconstruction surgeries performed annually.
Recovery often spans from nine to twelve months, pushing an athlete ten steps back in both their athletic career and personal life.
250,000+ ACL injuries occur annually in the United States.
"Experiencing a torn ACL is often described as hearing or feeling a “pop” in the knee at the time of injury. This sound is typically followed by intense knee pain and swelling."
— Alexander Orthopaedic Associates
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INSIDE THE INJURY
In seconds, during an ACL tear, the knee loses stability. The knee buckles, causing the shinbone (tibia) to shift abnormally forward and rotate beneath the thighbone (femur). This sudden, traumatic movement damages the ACL itself and frequently tears or strains the surrounding cartilage, meniscus, and stabilizing structures within the joint.
THE RISE
FORCE = MASS × ACCELERATION
Over the years, there has been a significant rise in ACL injuries due to year-round sports participation, lack of proper recovery, and increased training intensity among young athletes. Orthopedic surgeon Dr. Juliet De Campos, based in Pensacola, Florida, spoke to how the injury has evolved in recent years.
“It used to be only adults. The smaller you’re, the less likely you’re to have a big injury,” Campos shared. “A little kid playing football rarely tears their ACL. A middle schooler playing flag football hardly ever tears their ACL. But high school girls playing flag football have much higher incidents of ACL injuries than boys.”
— DR. JULIET DE CAMPOS
Campos continued to share that the rise also connects to physics: force equals mass times acceleration, due to the amount of flexibility vs. strength and power. As an athlete becomes older, stronger, and more explosive, a greater amount of force is placed on the knee, resulting in a higher risk of an ACL tear. Risks are dropping lower to high schoolers due to the greater participation in youth travel sports.
Studies have shown that youth sports have become a near $40 billion industry, which also leads to many not having the proper risk reduction strategies. There have been trends in the increase across high school, collegiate, and pro levels, continuously putting athletes in a stronger state of mental health challenges and the loss of identity when having to recover.
NIL & THE RISE
The Financial Incentive of Youth Performance
Opendorse, a leading sports technology company and athlete marketplace focused on the Name, Image, and Likeness (NIL) industry, states that, "from Olympic-level high schoolers to local standouts, many student-athletes stand to benefit from their name, image, and likeness. However, state-by-state high school athletic association rules shape whether and how these young athletes can cash in on their personal brand." With the rise of NIL extending to high school athletes, pressure on athletes continues to increase at younger ages, with greater exposure and competition leading to more burnout and injuries among younger athletes.
THE COST
The recovery process does not end when the athlete returns to play.
THE TRAUMA ON THE KNEE
When it comes to an ACL tear, there are several complexities that come with the injury. Orthopedic surgeon and sports medicine physician Dr. William Hill spoke to the long-lasting trauma and complexities involved in the recovery process.“The ACL is almost like a seatbelt and when that seatbelt comes off, the knee pivots in a way, what we call a pivot shift…that initial trauma is long lasting,” Hill shared.
After ACL surgery, those who have faced the injury are at a higher risk of developing arthritis in the knee. Long-term studies have shown that around 50% of patients who undergo ACL reconstruction have a strong possibility of developing osteoarthritis within 12–14 years. This is often due to the thigh muscle, known as the quadriceps, becoming weaker over time. Long-term weakness can lead to cartilage wear, joint damage, and arthritis in the years following the injury.
Chronic Pain •
Instability •
Swelling •
Re-tear Risk •
Arthritis
01 / THE BODY REMEMBERS
“It’s a life-altering injury, a career-altering injury, one that has lasting impacts on every aspect of your life: physical, mental, [and] career trajectory.”
— Dr. William Hill, orthopedic surgeon and sports medicine physician
02 / THE INVISIBLE RECOVERY
The Silent Recovery
Behind every physical injury comes the invisible injury: mental health. Athletes following an ACL injury face higher rates of anxiety, depression, and isolation. When athletes are forced into long periods away from competition and training, it can lead to a loss of routine, identity, and confidence in their ability to return and perform at the level they maintained prior to the injury.
A systematic review published in the Orthopaedic Journal of Sports Medicine states that “patients can develop negative psychological reactions, such as an increase in anger, negative emotions, and lower self-esteem."
Dr. Hill emphasizes supporting his patients through the emotional challenges that come with learning about their injury.“I talk them through it, [by saying] hey we can get through this, it’s a road of recovery ahead. But know that you have an ally and supporter in that road with you,” Hill shared.
03 / THE FUTURE OF THE KNEE
THE REBUILD
three ways surgeons can address an ACL tear through surgery:
ACL Repair
Autograft Reconstruction
Allograft Reconstruction
In high-level athletes, Dr. William Hill expressed that surgeons generally stay away from ACL repair due to studies showing that this particular repair has a high retear and reinjury rate. Another way to address the ACL is through allograft reconstruction, which uses donor tissue through the bone-patellar tendon-bone graft, quadriceps graft, or hamstring graft. For highly active athletes, surgeons can approach the injury through an autograft reconstruction, with studies showing a lower retear rate for individuals between the ages of 16–35.
DR. WILLIAM HILL, MD
Sports Medicine Physician & Orthopaedic Surgeon
SURGICAL PROCESS
THE COMEBACK
More Than a Return
Photo Credit: Jason Singarayer Photography
The Long Road Back: Annabel’s Silent Battle
Meet Annabel Macdonald, a professional freelance ballerina and USC alum. At a young age, Annabel found her passion. She spent most of her childhood perfecting her craft, training, and working toward a professional career in ballet. Annabel was born and raised in Washington, D.C. and grew up training in several ballet programs and schools, one being the The Washington School of Ballet, a classical ballet institution in Washington, D.C., known for its rigorous and extensive training.
In 2023, Annabel’s career and dream were put on pause and almost had no return when she tore her ACL, an injury that temporarily halted her career and challenged both her physical ability and artistic identity. Through surgery, rehabilitation, and a gradual return to pointe work, she shared the resilience required to rebuild strength, stability, and confidence. Annabel never imagined she would wear pointe shoes again or return to the ballerina she once envisioned becoming after tearing her ACL. Her story offers a reflective perspective on the long-term physical and psychological toll of recovery, losing the ability to pursue your dream, and what it truly means to feel like yourself again after injury.
Annabel is now based in Los Angeles as a professional freelance ballerina and creator who documents her ballet journey across social media. She performs with freelance companies, including the Freelance Ballet Collective, further living the dream she set for herself and inspiring those who once felt the same emptiness after returning from an injury.
Photo credits: APU Athletics and Cal State East Bay Athletics
The Long Road Back: DJ’s Silent Battle
Meet DJ Sanders, junior guard for Azusa Pacific University’s basketball team. Sanders has a fraternal twin brother named DM Sanders, who also attends APU, continuing a basketball journey the two brothers have shared since childhood. Growing up in San Diego, California, the Sanders brothers fell in love with basketball, from their mother adding a hoop in their room to the twins playing on the same teams throughout high school and college. Their shared passion for the sport continued to grow over the years.
DJ Sanders attended Bonita Vista High School, where he made a name for himself early on as a standout athlete, two-time All-League selection, two-time Basketball MVP, and Bonita Vista’s Athlete of the Year as a senior, all while leading his high school to a CIF Championship during his senior year. Beyond sports, he achieved academic excellence as part of the Black Student Union in high school while earning the President’s Education Award, Distinguished Athlete Award, and Outstanding Academic Excellence honors. He embodies what it means to be a student-athlete and balance the demands of basketball while maintaining excellence in the classroom.
Prior to APU, Sanders attended California State University East Bay, where he faced several injuries throughout his collegiate career. Now at APU, he is facing the biggest obstacle of all. On January 13, 2026, Sanders tore his ACL during an away game with the Cougars, a moment when everything went silent.
Since then, DJ has been on the road to recovery, from surgery to physical therapy to pool workouts, and isn’t stopping there as he envisions himself returning to the court at the start of next season.
The Prevention
FIFA 11+ injury prevention program
Recovering from an ACL injury requires more than consistent months of training. For some athletes, the recovery process can also bring significant out-of-pocket costs depending on whether they are part of a program or receiving outside rehabilitation support. The price of rehabilitation can cost anywhere between $20-$250 per session, with around 20 or more sessions needed over the next few months of rehabilitation.
Throughout the years, there have been several prevention plans put in place to help limit the number of ACL injuries, such as the FIFA 11+ injury prevention program that was developed by a comprehensive group of international experts and targeted at football players aged 14 and up. According to the American Medical Society for Sports Medicine, “Scientific studies have shown that youth soccer teams who adopted the 11+ program had lower rates of injury as compared to teams who warmed up as usual.” The program is focused on movement training and body control to handle force properly. Tying back to the concept of Force = Mass x Acceleration, the program teaches the body how to absorb force and stabilize movement. Therefore, FIFA recommends that youth soccer teams should implement the program as their sole warm-up routine. Dr. Juliet De Campos also shared success stories about the program and how it has helped many athletes prevent ACL tears.
DR. JULIET DE CAMPOS
SURGICAL INSIGHT / PREVENTION
Recovery may begin after the tear. Prevention begins long before it.
REPORTER
Meet the Journalist
Alana Morgan Perkins is a sports journalist and recent graduate of USC Annenberg’s Specialized Journalism master’s program, earning her M.A. in Specialized Journalism and B.A. in Journalism from Loyola Marymount University. As a former track and field athlete, her reporting often focuses on the deeper human side of sports, highlighting the stories, challenges, and experiences athletes face beyond competition. Ten Steps Back was inspired by her own experience recovering from injury and aims to provide a deeper understanding of the physical and psychological journey athletes endure throughout rehabilitation and recovery.