ACL : why you need an On-Field Rehabilitation program before returning to play...
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
Restoring Physical Conditioning and
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
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Lionel Pannunzio
Physical Therapist
Board-Certified Sports Specialist
Owner of White Bay Physical Therapy