Life After ACL Reconstruction: Return to Sport is Where the Work Starts

The hard side of sport is seeing an athlete train, prepare for a season and suffer a serious injury. It just isn’t fair. Nobody deserves that. This is often the case with ACL injuries and ACL reconstruction.

Anterior Cruciate Ligament (ACL) injuries are one of the most common knee injuries in field sports. The rate of ACL injuries that are operated on is about 100,000 per year in the United States with 70% of these injuries sustained with non-contact mechanisms (twisting, cutting). If you haven’t seen Michael Owen from the 2006 World Cup do so, let me remind you. 

When rehabbing and preparing an athlete returning to sport, the goal must be keeping them there! In doing so, it is important to consider time trends of ACL injury, complication rates before returning to match play, and the influence of reconstruction over the athlete’s’ playing career. 

In English soccer, a recent study revealed only 65% of players are still playing at the top-level in which they injured themselves initially, 3 years after ACL reconstruction. This number needs and must be higher. Even though return-to-play within one year is 76% and some research showing even higher, 90-100%, movement deficits still remain for much longer, greater than a year!  This is where the fine details matter most.

In physical therapy and strength & conditioning, there is always evolution of treatment
strategies and test measures. For example, there is a large amount of evidence pointing to norms in hop tests for determining return-to-sport for both male and females in high school and college. These are great numbers to target and should be a goal. That being said, what they tell you is that you can (or can’t, but we are optimistic here) jump equally as far on each leg. This shows “symmetry” or lack thereof. What these numbers don’t tell you the quality of these hops or the quality of which you land or change direction.

This is where in-depth and specialized screening comes into play. This needs to be started by looking at 3-dimensional functional mobility and stability. Using the Functional Movement Screen (FMS) is the perfect place to start. It is used on the elite level from the LA Galaxy and Barcelona F.C.  to the Olympic gymnastic team. The FMS is clear-cut and assesses ability in static positions. If an athlete cannot prove to be efficient in static positions then they definitely are not ready to push themselves in fast, powerful, dynamic moves–running, jumping, cutting (which can put quite a bit of stress on your ACL).

As you can see in the inline lunge, the image on the left is perfectly executed. The image to the right shows his shoulders shifted to his left with his right knee flaring out to his right. This is clearly something that needs to be corrected.

In the rehab and training process, you will often times hear an emphasis placed on preventing the knee from going into genu valgum (knock kneed or knees diving in) or staying in “neural.” Nobody is wrong in that regard however when we are talking about performance and return to sport, the game has to change. This should be a skill and a movement quality that has been corrected in the first year, and quick as possible.

When you are on the field or in a game, your body will be challenged and put into positions you may not have encountered during physical therapy or training. What bridges the gap between the gym and the game, staying injury free, is not your ability to avoid positions outside your comfort zone but your ability to get yourself out of them when you are in them because it is inevitable! I.E.. a hard plant and turn on the field, your knee dives and you are strong enough and have good motor control to correct it instead of ending up on the ground! You need to have the ability to react and adapt, not avoid! 

Can you guess when you are most likely to have a knee injury during a game? Are you thinking later in the game as players are getting more fatigued and don’t have as much strength to keep themselves safe? Many people would probably say the same but the evidence points to these injuries being more likely to happen early in a match or to newly subbed in players. These are usually intense periods of the game and put your body under higher demand. That being said, it doesn’t mean we cannot do a better job of prepping you for this. Game prep for starting a game or subbing into a game should mimic these situations so the first time you have to plant, turn, sprint and cut isn’t on the field. 

If we want better results, we have to move towards a different and better approach. Programing always needs to have a goal in mind and specific to what should be accomplished. Adapting more evidence-based proprioceptive training in addition to therapy and strength & conditioning program is essential. It is also important to have everyone working closely together–PT, strength coach, head coach– for integration into games and practice.

If you are interested in learning more, I’d love to hear from you. Leave a comment and shoot me an email HERE

References

1. Waldén M, et al. ACL injuries in men’s professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med 2016;50:744–750 
2. Daniel DM, Stone ML, Dobson BE, et al. Fate of the ACL-Injured Patient. A prospective Outcome Study. American Journal of Sports Medicine.1994; 22:632-644.
3. American Academy of Orthopaedic Surgeons, July 2007, Anterior Cruciate Ligament Injury: Surgical Considerations, http://orthoinfo.aaos.org/topic.cfm?topic=A00297#A00297_R4_anchor (August 27, 2016).
4. Bahr R, Thorborg K, Ekstrand J. Evidence-based hamstring injury prevention is not adopted by the majority of Champions League or Norwegian Premier League football teams: the Nordic Hamstring survey. Br J Sports Med 2015;49:1466–71.
5. Rahnama N, et al. Injury risk associated with playing actions during competitive soccer. Br J Sports Med 2002;36:354-359