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ACL On-Field Rehabilitation


The last two blogs posts we tried to explain the complexity of an ACL tear and the process of returning to play after the surgery.


Today we will focus on field work



The two main goals of an On-Field program are


  1. Restoring Physical Conditioning and

  2. Movement Quality



Restoring Physical Conditioning






During a typical soccer match, top-level outfield male players cover up to 13km, at an average intensity close to the anaerobic threshold (ie, 80%-90% of maximal heart rate).


Soccer players are constantly accelerating and decelerating in high-intensity intervals of 4 to 6 seconds.


This activity is supported by the Anaerobic system ( Anaerobic glycolytic sources).


Therefore during the rehabilitation process this Anaerobic Glycolytic system needs to be developed again.

Video 1 shows a progressive sprint series with constant change of rhythm 25 to 50% , 50 to 75 % , 75 to 90 % , start , stop, accelerate , decelerate , 4-6 seconds on, 4-6 seconds off .

Fatigue plays an important role in many injuries that’s why training to become resistant to fatigue is a key component of the on-field rehabilitation.

Research has shown that fatigue may increase the risk for ACL injury.

When we have a fatigated player and we add an unanticipated movement (very typical in soccer ) the risk for ACL injury or any other injury increases substantially .


Once some level of fitness has been achieved the On-Field rehab must include game situations.



Moving quality



After the player has some physical fitness and has conquered the linear task , preplanned multidirectional movements of increasing speed and complexity need to be added to the On-Field Rehabilitation.

Video 2 shows preplanned “cutting” movement with an angle progression of 135 to 90 to 45 degree cuts without and with ball.

The goal of this more complex task is to challenge the Limb to change directions.


Gym based exercises do not directly improve movement quality during sport-specific movements. There is a need to incorporate sport-specific movement practice to relearn and improve movement coordination during sport-specific movements.

It is essential to train motor control progressively with small increments in movement complexity.

Therefore , once the player can manage high-speed linear running, accelerations, and decelerations, more complex multidirectional and change-of-direction drills, can be added to the rehabilitation program. This drills must be done at or near full capacity / speed to continue training energy systems especially with anaerobic demands . It is very important that there is no clear deficits in biomechanics or poor form to avoid training a faulty movement. In this video player is required to move quick side to side over small hurdles balance on one leg and kick. Immediately after the kick accelarate in the opposite direction and repeat .


Also here, player will accelarate forward backwards diagonals and jump to head the ball.





Continuing with more complex activities the player will initiate practicing preplanned soccer-specific drills and game situations. First with no pressure. Then adding external demands and more neurocognitive demands to challenge the athlete. Reactive-movement: for example running forward and changing direction at the cone, either right or left, depending on how the player reacts to the cue presented immediately before the required task.

In this video the player will react to clues or instructions or just react to game situations. . Player contact should be also added to challenged automatic body reactions to adapt to the situation.


Return to Practice

Once a player can demonstrate he or she is safe to execute high-speed multidirectional movement drills while fatigued , the next stage is to progress toward team practice. Now the player can participate in modified team practice for example join in the warm-up and technical skills sessions, with his teammates. Emphasize group-based technical and tactical drills, including possession drills in 1-versus-1 and 2-versus-2 situations.

The player must perform at a minimum of 90% of the required practice intensity and complete at least 90% of the preinjury training volume .


In addition, the soccer player should have reached at least 70% of the preinjury chronic training load (or relative to normative values) in all relevant physical workload metrics.

Criteria for return to unrestricted team practice include


  • clinical: pain, swelling, stability/laxity, range of motion,

  • functional :strength, endurance, body composition,

  • biomechanical: movement analysis testing,

  • psychological fear of re-injury, confidence, and

  • sport-specific ability to support volumes and work intensities in training, sport-specific physiological screening factors.



Conclusion


  • ACL Patient must undergo a long rehabilitation process not only in the clinic setting but also on the field .


  • The two main goals of On-Field Rehab are Restoring Physical Conditioning and Movement Quality


  • Research has shown that fatigue may increase the risk for ACL injury reason why physical conditioning is necessary during the on-field rehab


  • The player must be able to manage high-speed linear running, accelerations, and decelerations, complex multidirectional and change-of-direction drills before allowing practicing with the team, all pillars of the On-field program


  • Patient must demonstrate full capacity before returning to play.




Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries.

With more than 20 years of experience helping athletes return to their sports after an injury.

He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy



Introduction



Many people don’t know the magnitude of an ACL injury. It goes far beyond just the physical struggles as the psychological is equally affected.

Returning to sport after injury is a complex multifactorial process and requires a biopsychosocial approach.

Patients with ACL injuries will require an extensive Rehabilitation Process ( 9+ months ).




Phases of Rehabilitation







This extremely long Rehabilitation process can be divided in 5 phases:


  • Clinic-Based rehabilitation,

  • On-field Rehabilitation,

  • Return to Training,

  • Return to Competitive Match Play, and

  • Return to Performance


Note that the Rehabilitation of an ACL does not end when the player returns to play but continues till the patient achieves maximal performance.


In the last decades there has been a stronger focus on better preparing the athlete for the demands of his or her sport.

A good Return-to-Sports (RTS) plan must include a performance-based recovery process that takes the player in a continuum of on-field rehabilitation, safe return to team training, safe return to competitive match play, and safe return to performance.





The importance of an "On Field Rehabilitation Program"






ACL patients will need an extensive on-field rehabilitation in addition to Clinic Rehab to assure a safe return to play.


The goal of on-field rehabilitation is to support athletes in their transition back to the sport after an ACL injury ( or any other injury) , from standard rehabilitation to return to the team or practice.


A dual focus on rehabilitation factors and sport-specific performance requirements is essential to test player readiness to return to play reducing the risk of a second ACL injury

The 4 pillars of high-quality on-field rehabilitation:


  1. restoring movement quality

  2. physical conditioning

  3. Restoring sport-specific skills

  4. progressively developing chronic training load.



Restoring Movement Quality

An ACL injury results in altered movement bilaterally which indicates that there is a necessity for movement reeducation that goes far beyond the Gym based exercises . Players need to train with Soccer-Specific exercises on the surface you play ( grass / turf ).


Physical Conditioning

An outfield players will cover up to 13 km, at an average intensity close to the anaerobic threshold (ie, 80%-90% of maximal heart rate) in a game.


Players repeat high-intensity bouts of activity every 4 to 6 seconds supported by anaerobic glycolytic sources. Aerobic metabolism supports less intense plays.


These capacities must be restored during on-field rehabilitation to expose the players to the demands of the sport.


Players need to demonstrate safe fitness and agility levels: Running speed at lactate threshold with yo-yo intermittent recovery, Speed : 30-m sprint running, and Agility : 5-0-5 change of direction test, the T test or pro-agility test.



Restoring Sport-Specific Skills

The technical and tactical components of soccer form 3 distinct groups: individual technical skills, One on One play, small-group play, and full-squad play.

Progressively Developing Chronic Training Load

To guarantee that the player has been exposed to enough training to restore all the qualities mentioned above.





ACL On-Field Rehabilitation


A very recent study proposes an On-Field program that moves through 5 field-based training stages:


  1. linear movement

  2. multidirectional movement

  3. soccer-specific technical skills

  4. soccer-specific movement

  5. practice simulation.


1. Linear Movement

With very “controlled” activity the player starts contacting the soccer ball and involving in basic linear task. Goal: short sessions and restore movement quality

2. Multidirectional Movement

Multidirectional movements are added at or near full speed and without poor biomechanics or hesitation. The player will progress to more complex change-of-direction drills.


3. Soccer-Specific Technical Skills

Player will start training “agility” which includes movement with reactive decision making Technical training involves practice of preplanned soccer-specific drills cutting while reacting to an external stimulus.

4. Soccer-Specific Movements

This stage is to progress toward team practice intensity (eg, 85%–90%), including 1v1 drills under match-type scenarios. Drill’s Complexity will increase so the player has to able to perform high-speed multidirectional movements with fatigue. Training load : average heart rate and minutes at an intensity of greater than 85% of maximum

5. Practice Simulation

Stage 5 aims to bridge the gap between on-field rehabilitation and unrestricted team practice with the final goal of returning to unrestricted practice with the team. This is the stage for modified team practice like joining the team for the warm-up and technical skills sessions.

Training load should be at a minimum of 90% of the required practice intensity and complete at least 90% of the preinjury training volume.


  • Criteria for return to unrestricted team practice includes

  • clinical: no pain, swelling, stability/laxity, full range of motion,

  • functional: strength, endurance, body composition,

  • biomechanical: movement analysis testing,

  • psychological: fear of reinjury, confidence, and

  • sport-specific: ability to support volumes and work intensities in training, sport-specific physiological screening factors.





When can I return to play after an ACL repair ?




One study in the British Journal of Sports Medicine ( Grindem et al 2016) evaluated Patients who returned to level I sports after surgery  and They found that  reinjury rate was significantly reduced by 51% for each month RTS was delayed until 9 months after surgery, after which no further risk reduction was observed.


Despite some success in early return to sports, most surgeons allow their patients to return to a Level I sport after 9-12 months.


Time questions aside,  I don’t allow a return to Level I sport (soccer, basketball, football) after an ACL reconstruction until there is no pain with activity, no swelling, full range of motion, good stability, strength close to equal to the opposite side.


Then the patient has to pass a series of rigorous functional tests of neuromuscular control.  If they pass this, only then, with full awareness of the risks involved, are they released to a sport.  


It typically takes at least 9-12 months to achieve all of these goals after ACL surgery.


At the recent AOSSM meeting in Seattle, a symposium paper was presented on “pediatric” ACLs.  This included patients up to 17 years old.  With careful analysis, they noted that significant neuromuscular control deficits persisted past 11 months in almost all patients.  They strongly cautioned against returning to sport prior to these deficits being corrected.


Besides the typical in-the-clinic rehabilitation ACL patients will need extensive on-field rehabilitation to assure a safe return to play.

At White Bay PT we specialize in this transitional rehabilitation that will take the patient from clinic to field ensuring a safe return to play.





Is Progressively Developing Chronic Training Load the best way to avoid a second ACL injury?




After years of ACL surgeries the outcomes following these long-term injuries are still unsatisfactory compared to other injuries.


Approximately 50% of patients do not return to the same competitive level of activity after anterior cruciate ligament reconstruction (ACLR), and as many as one third of young, active patients with ACLR sustain a second anterior cruciate ligament (ACL) injury within 2 years of returning to activity.

ACL re-tear rates are approximately 20-25%. That means one in every four to five athletes are suffering a second ACL tear.

There is no clear consensus on when the player is ready to play after an ACL injury.

Training load: a key factor in ACL rehabilitation. Load progression is a key part of every rehabilitation protocol. Too much too soon rehab / training may increase risk of reinjury , not enough rehab / training may also increase risk.

Basically what we are trying to do here is to expose these patients to enough practice and repetition of the skills necessary to play to allow the body to re-adapt to the sport. . Unfortunately this process takes time and knowledge. We follow this general progression of : linear movement, multidirectional movement, soccer-specific technical skills, soccer-specific movements, and practice simulation, practice with the team, scrimmages, 20-30 min of real game time, half- game, full game.

This continuum of progressively challenging the repaired ligament and the kinetic chain will expose the player to sufficient repetitions to match the demands of the game.

Prolonging rehabilitation and RTS might reduce the risk of subsequent injury by nearly 5-fold because it allows more time to re-train the player.

Therefore, progressively developing and obtaining sufficient chronic load are essential elements of on-field rehabilitation.


If you want more information about ACL injuries be sure you see our previous post on this topic see previous post




Conclusion:


  • ACL repair surgery in a very complex condition and it needs a personalized approach with the help of a specialized health professional

  • ACL re-tears are still very high which may mean players are returning to play without completing the rehabilitation process

  • On-Field training is a must for ACLR patients

  • Delaying the return to play for +9 months decreases significantly the rate of re-injury (21%)




Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an ACL injury.

At White Bay we offer the whole package, from typical rehabilitation in a clinic setting to a complete On-Field program aimed for restoring players sports skills before returning to play


Lionel is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page

where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.


Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy

“Keeping Athletes in the game”


Introduction


ACL Tears are one of the most devastating injuries in a Soccer Player. There is a still a big number of patients that never return to play or they return to play to a much lower level than before the injury. In this post we outline all the components of an ACL injury. The more you know the better decision you'll make when recovering from this condition




ACL - Anatomy



The knee is a hinge joint where the thigh bone (femur) connects to the shinbone (tibia).


The quadriceps muscles in the front of the thigh and the hamstrings in back help to stabilize the knee, but stabilization occurs primarily from the knee ligaments.

There are 4 ligaments that keep the knee stable and moving in the proper direction.

The medial and lateral collateral ligaments keep the knee from shifting 𝐬𝐢𝐝𝐞 𝐭𝐨 𝐬𝐢𝐝𝐞, while the anterior and posterior cruciate ligaments keep the knee from sliding 𝐟𝐫𝐨𝐧𝐭 𝐭𝐨 𝐛𝐚𝐜𝐤.

The ACL attaches the lateral femoral condyle to the tibia just in front of the anterior tibial spine. Some of its fibers also blend into the medial meniscus.

There are actually two bundles of fibers that make up the ACL and allow it to help stabilize the knee in flexion (bending), extension (straightening), and rotation. It works as a passive stabilizer that with the assistance of the Muscles (active stabilizers) helps  maintaining the bones of the knee joint (femur and tibia) from moving too much, keeping the knee stable for  jumping , cutting , changing direction, and decelerating during high level sporting activities. The ACL resists forward ( anterior ) translation and inward ( internal ) rotation of the tibia in relation to the femur.




Mechanism of Injury




The 2 most common mechanisms for an ACL tear are:


1. Non-contact Injury

Rapid deceleration with the knee slightly bent and the tibia rotated internally or externally . For example landing from a jump , pivoting,  changing directions.



2. Extreme hyperextension or from a direct impact to the outside of the knee.


Knowing the most common mechanism is very important for treatment and especially for prevention. Soccer teams around the world work on extensive balance exercises , landing from a jump exercises , single leg coordination exercises to maintain a healthy knee.


All this mechanism must also be reproduced during the last stage of the rehabilitation program to assure patient is ready to safely manage these demands to the knee and the ACL.







ACL Tear Facts




In non contact injuries, the person is usually changing direction quickly, making a sudden stop or landing from a jump. In contact sports, the foot is usually planted and the blow causes knee hyperextension. High-risk sports include football, basketball, soccer, and skiing. The use of cleats also increases the risk of an ACL injury. Women are at higher risk of sustaining an ACL injury than men. Potential reasons for this increased risk may include differences in anatomy, training, and activity experience.

Genetic differences in how muscles contract may also be another reason for the increased risk in females. Furthermore, women have a wider pelvis than men to accommodate childbearing, and this can cause an increased angle where the femur meets the tibia at the knee joint (Q angle). A wider angle increases the stress on the ACL, increasing the risk of injury. The male's larger quadriceps and hamstring muscles bulk tend to protect and stabilize better a women's quads and hamstrings, if the same stress is placed on the knee joint.




Symptoms of an ACL Tear



  • The patient usually can notice a loud popping sound as the ligament tears.

  • Pain is almost immediate.

  • Knee swelling occurs within an hour or two as blood from the ruptured ligament fills the knee joint.

  • Walking is difficult, and the knee feels unstable or like it will give out because of the fluid within the joint, it may be difficult to fully extend or straighten the knee.

  • The initial treatment may include ice for pain and inflammation management, and due to the instability of the knee and problems walking athletes need to use crutches and a knee brace for protection.




ACL Treatment Options


There are 3 options when it comes to fixing your  ACL for your injured knee.

1. Reconstruction

Most patients will require surgery if the want to return to long term high level sports

The most common surgical procedure is the ACL reconstruction. ( see below for reconstruction surgery options)

2. Repair

ACL repair is a good option but it’s only for a slightly torn ACL which is a less common type of injury . Usually the ACL tears completely in the middle of the ligament causing damage beyond repair and needs to be reconstructed

3. Rehabilitation without surgery

Finally there are certain patients that the will “cope” very well with the rehabilitation process and the knee feels stable enough to do “less risky “ physical activity or sports and can avoid the surgery altogether. See Picture below for more "facts" about non-surgical rehabilitation of complete ACL tears










ACL Surgery - Reconstruction and Graft Options




There are several options that surgeon will choose for an ACL reconstructions surgery


  1. BONE-  PATELLAR TENDON - BONE

  2. HAMSTRING TENDON

  3. QUADRICIPITAL TENDON ( YOUTH )

  4. ALLOGRAFT ( CADAVER )

The different types of ACL reconstruction options require using a “graft” as the replacement for the completely torn ACL.


A graft is a living piece of tissue that is transplanted surgically.


The different types of ACL grafts one can choose from are: the two most common are hamstring tendon graft, patellar tendon graft from your own muscles and tendons.


Another option could be a graft from a cadaver called allograft and the 4th option is the quadriceps tendon graft ( mainly for youth athletes).


The rehabilitation of these types of graft is very similar and the outcomes are very similar as well in term of success to return to play and re-injury rates.


Patellar Tendon graft are associated with a higher patella and patellar tendon issues than hamstrings or cadaveric graft



Conclusion


  • ACL tear is a devastating injury for any Soccer player, most common in female soccer players


  • There are a few specific cases that will cope well with rehabilitation without surgery


  • It will require surgery in most cases using a graft to reconstruct the ACL and a long rehabilitation process ( + 9 months ) to return to play.


  • A good amount of patients ( 25-50 % ) will never return to their previous level of activity reason why the rehabilitation process is crucial in this patients.









Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries.

With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located  in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages

Finally we would like to invite you to follow us  at our:

Facebook Page

Google Plus Page

Instagram Page


where you will receive information about your condition and other services we offer, always with the idea of keeping you healthy and fit to enjoy your favorite sport.

Lionel Pannunzio

Physical Therapist

Board-Certified Sports Specialist

Owner of White Bay Physical Therapy