A torn ACL can remove a teenager from competition in a second. It can also separate them from their friends, disrupt the rhythm of their family and unsettle an identity built around being an athlete. The MRI captures the damaged ligament. It does not show everything else the injury has taken away.
That distinction has shaped the sports medicine model Mininder Kocher, MD, has built at Boston Children’s Hospital. The division he leads brings orthopedic surgeons together with nonsurgical sports medicine physicians, physical therapists, athletic trainers, behavioral health specialists, researchers and injury prevention experts. The aim is not merely to repair an injured knee, shoulder or hip. It is to understand why the injury occurred, how it is affecting the child and what must change before the athlete returns.
“The vision was really to provide holistic care for the patient,” Dr. Kocher, chief of the sports medicine division at Boston Children’s, O’Donnell Family Endowed Chair and a professor of orthopedic surgery at Harvard Medical School, told Becker’s. “We could see a patient, diagnose them, treat them and then just send them on their way. But we would often see them coming back with repeat injuries, or they had some underlying issue that wasn’t really being addressed.”
That realization led Boston Children’s toward a different definition of a successful sports medicine program. The operation matters. So do the months before and after it.
What the injury does not explain
Consider a young runner with a tibial stress fracture. A conventional treatment pathway can identify the fracture through imaging, remove the athlete from competition and allow the bone to heal. All of that may be medically appropriate.
It may still leave the most important question unanswered: Why did the bone fail? The athlete may be overtraining. Low bone density, inadequate nutrition or irregular menstrual cycles may be contributing. Running mechanics, such as overstriding or excessive force at heel strike, may repeatedly load the same part of the tibia.
Without addressing those factors, treatment can become an intermission between injuries.
At Boston Children’s, the athlete may move among medical evaluation, nutrition, behavioral health, physical therapy and biomechanical analysis. When the runner is ready to return, specialists can assess the mechanics of the stride and modify patterns that may have increased the original risk.
The model treats the stress fracture as evidence rather than the whole problem. That same philosophy extends across the division’s care for ACL tears, overuse injuries, hip conditions and other pediatric sports problems.
The care pathway begins before the hospital
Boston Children’s tries not to wait passively for injured athletes to find the health system. Its orthopedic surgeons and sports medicine physicians work as team physicians for schools, colleges, youth leagues and athletic events. Those relationships give the program a direct connection to the athletic trainers often standing closest to an athlete at the moment of injury.
When a high school player tears an ACL, the school’s trainer may already know whom to call. The program works to evaluate the athlete within a week. A surgeon or nonsurgical sports medicine physician can perform the initial assessment, arrange imaging and begin building the treatment plan.
That speed matters clinically, but it also matters emotionally. A teenager who has suddenly lost a season does not experience the injury as an abstract orthopedic problem. The athlete wants to know what happened, whether surgery is necessary and when life may begin to feel normal again.
Once an ACL tear is confirmed, the program can begin physical therapy before surgery, a process often known as prehabilitation. At the same time, clinicians introduce another part of recovery that may otherwise remain unspoken: They ask how the athlete is coping.
A season-ending injury rarely ends with the season
For many adolescents, sport is not simply an activity. It determines where they go after school, who their friends are and how they understand themselves. Competitive schedules can also organize family life around practices, tournaments and travel. An injury can disrupt that entire system.
“When you take an injured athlete and their identity and peer group are tied around the sport, it’s a big loss,” Dr. Kocher said. “It can be difficult for the whole family unit because often these families are very tied to youth sports.”
The psychological effect may be intensified by a broader rise in anxiety and other behavioral health challenges among children and adolescents, he said. Yet the mental side of recovery can remain invisible unless someone asks about it directly.
Boston Children’s has behavioral health clinicians embedded within its sports medicine model. They are not distant consultants brought in only after a crisis, they work alongside the physicians, therapists and trainers caring for the athlete. Clinicians normalize the possibility that an injury may cause fear, grief or depression, and make resources available before those emotions begin interfering with recovery.
“We care not just about the ligament in that knee, in that leg, in that patient, but the whole patient and the whole family,” Dr. Kocher said.
Nine months is not a finish line
An athlete may be medically cleared nine months after ACL surgery and still be unprepared to compete. Boston Children’s does not treat time alone as proof of readiness.
Before returning an athlete to sport, the program evaluates range of motion, strength and functional performance. Athletes may complete hop tests, jump-landing assessments and other exercises designed to reveal deficits that a routine examination could miss. Some pass. Others still show weakness or movement patterns that require additional rehabilitation.
The program also examines psychological readiness through tools such as the ACL Return to Sport After Injury scale. An athlete who remains afraid of reinjury may hesitate, alter movement patterns or avoid fully engaging in competition. That fear is not merely an emotional obstacle. It can shape how the body moves.
“If they get back to sports and they’re fearful, they move in a certain way that actually makes them more likely to get injured,” Dr. Kocher said. Return-to-sport decisions therefore combine physical testing with an assessment of confidence and readiness. When problems emerge, physical therapists and behavioral health specialists can intervene before the athlete returns to an unpredictable field or court.
The goal is not to delay athletes unnecessarily. It is to prevent a calendar from making a decision the athlete’s body is not ready to support.
The other knee remains at risk
An ACL reconstruction can restore stability to the injured knee. It does not erase the factors that made the athlete vulnerable. In one Boston Children’s study of younger, prepubescent patients, the risk of retearing the reconstructed ACL was between 6% and 7%, Dr. Kocher said. The risk of tearing the ACL in the opposite knee reached as high as 12%.
That finding changes the purpose of rehabilitation. The program cannot focus only on protecting the graft. It must examine movement patterns across both legs and identify the strength, coordination or landing mechanics that may contribute to another injury.
“We really need to be working on both knees and understanding what movement patterns put them at risk for the first injury so we can avoid a second injury,” Dr. Kocher said. Injury prevention is therefore not an optional program added after recovery. It is part of the treatment itself.Many health systems say they want multidisciplinary care. Building it requires more than creating a referral list. The difference, Dr. Kocher said, is whether specialists operate as a single team or continue working within traditional departmental boundaries.
“If we looked at sports medicine as only an orthopedic issue, then we would have only orthopedic surgeons treating the patients,” he said. At Boston Children’s, physical therapists and behavioral health professionals are embedded within sports medicine rather than simply receiving occasional referrals. They share clinics, communicate about patients and develop familiarity with the demands of athletic recovery.
That structure can challenge the way hospitals are traditionally organized. Physical therapy, psychiatry, psychology and orthopedics each have their own leadership, budgets and workflows. Embedding specialists across those lines requires support from the health system.
“It takes leadership at the division level, but particularly at the hospital level, to recognize that breaking down these silos and having multidisciplinary clinicians working together improves the quality of care and the outcomes,” Dr. Kocher said.
Without that support, multidisciplinary care can become a series of handoffs. With it, the team can function horizontally around the patient.
Measuring more than the operation
The model also depends on knowing whether the additional coordination changes results. Boston Children’s uses both patient feedback and clinical outcomes to assess its work. The division tracks return to sport, whether athletes regain their previous level of competition and rates of reinjury in both the treated and opposite limbs.
Much of that data is collected through the division’s Sports Medicine Research, Technology and Innovation unit. Patients participate in prospective research protocols and receive questionnaires at multiple points in their recovery.
Those responses allow the program to follow physical function, return to activity and reinjury over time.The measurement matters because multidisciplinary care is resource-intensive. It requires health systems to invest in professionals and services that may not be directly connected to an operation. The case for the model becomes stronger when leaders can show not merely that families appreciate the experience, but that athletes return more safely and sustain those results.
The injury problem begins outside medicine
Even the most integrated sports medicine program operates downstream from a larger force: the transformation of youth sports into a year-round industry.
Children have less free play, Dr. Kocher said. They enter organized competition earlier, specialize in one sport sooner and may play on club teams that prioritize tournaments and games over practice and recovery.
The structure increases exposure. Athletes may play several games in one day. Fatigue accumulates. Injury risk rises.
“There are structural issues about the youth sports paradigm,” Dr. Kocher said. “It’s a big industry that’s driving this and contributing to these injury patterns.”
That is a problem no surgeon can solve in the operating room. It requires public education about early specialization, year-round competition, rest, training volume and the risk created when a developing body repeatedly performs the same movements without sufficient recovery.
Boston Children’s views that communication as part of its responsibility. A pediatric sports medicine program should not only become better at repairing injuries, Dr. Kocher said. It should also help communities understand why more children are getting hurt.The point is not to frighten children away from sports. It is to keep them participating safely.
Dr. Kocher sees return to sport as more than a clinical outcome. Athletic participation can support physical health, social connection, confidence and long-term well-being. Children and adolescents who remain active in sports tend to have lower rates of obesity and better behavioral and educational outcomes, he said. They may be less likely to use drugs or leave school and may carry the benefits of participation into adulthood.
That makes pediatric sports medicine part of a broader public health project. The surgeon repairs the ligament. The therapists rebuild strength. The psychologist helps restore confidence. The athletic trainer reconnects the child to the team. The injury prevention specialists work to keep the next injury from occurring.
Success is not simply an intact graft on an MRI or a stable knee during an examination. It is a young athlete returning to the activity they love without leaving the rest of themselves behind.
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