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:
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:
restoring movement quality
Restoring sport-specific skills
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 ).
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:
soccer-specific technical skills
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
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
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Board-Certified Sports Specialist
Owner of White Bay Physical Therapy
“Keeping Athletes in the game”