Anterior Cruciate Ligament injury and the return to training
Anterior cruciate ligament injury is a common injury in football, across all levels of practice, from amateur to elite.
This injury, most often requiring surgery, has an estimated time for return to play of around six months after the intervention aiming the ligament replacement. However, often players make earlier returns, with a lot of credit attributed to the rehabilitation process.
But should be the time to return to training a competition a direct indicator of the rehabilitation success? Is it enough for a player to present a knee with no inflammation signs, full range of motion and ability to make a few drills with the Physiotherapist or other rehabilitation professional or earlier returns may well be associated with a higher risk to other injuries? Can a player be at higher risk to sustain different injuries besides the one that recent affected him under the influence of some form of strength, power or coordination deficits?
Should not a player return form the ACL make a separate conditioning program, if possible considering previous training data available that could guarantee that physically he will not suffer a high impact on his body when returning to train with the team?
The ideal rehab process in our opinion
In our experience and considering the rehabilitation cycle a player needs to go through the rehab it seems doubtful that any return following an ACL happening in less than 4,5 or 5 months after surgery will have fulfilled all the proper stages of rehab. This is based on the protection phase that normally is required after the surgery, the strength program the knee needs to perform, the neuromuscular control at the several range of motions points along with the knee functional ability, and ultimately the outfield conditioning program that is a fundamental stage of the rehab.
Skipping any of these stages and their associated markers may represent a higher risk for low performances and aggravated risk of associated injuries either in the recent operated knee or other structures.
Markers after an anterior cruciate ligament injury
Our suggestion of markers after an anterior cruciate ligament injury includes:
- No effusion
- Full range of motion
- Coordination/balance tests symmetric between sides (Star Excursion Balance test, squat range in horizontal and vertical hop activities, Tuck jump)
- Apprehension test negative
- Knee isokinetic dynamometer test with deficits inferior to 10% at concentric quadriceps and hamstrings at 60º/sec and 240º/sec and 30º/sec eccentric hamstrings. Functional ratios of 1,4.
- Calf test strength and hip extension (leg press) inferior to 10%.
- Vertical and triple hop measures inferior to 10%
- Completion of progression of outfield parameters for total distance, maximum speed, high intensity, medium and maximum accelerations and decelerations.
Even considering all these markers the player´s adaptation to the team tactical and physical demands also must be taken into account before competition is considered. The higher cognitive complexity and emotional factors present when returning to team training, along with the tactical demands and number of elements, all factors that cannot be reproduced in a rehab context, require a period where the player should be given an opportunity to overcome this adaptation as well. Thus, ideally, the player should be involved in a non-official match before returning to play official games.
This way even taking into an account a player with a previous anterior cruciate ligament injury surgery has an elevated risk of injury, we consider that this approach may help minimize that risk.
Alentorn-Geli E, Myer GD, HJ, Samitier G, Romero D, Lazaro-Haro C, Cugat R. (2009). Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee Surgery, Sports Traumatology, Arthroscopy, 17: 705-729
Beiser TF, Lloyd DG, Cochrane JL, Acland TR (2001). External loading of the knee joint during running and cutting maneuvers. Medicine and Science in Sports and Exercise, 33: 1168-1175
Beiser TF, Lloyd DG, Acland TR, Cochrane JL. (2001) Anticipatory effects on knee joint loading during running and cutting maneuvers. Medicine and Science in Sports and Exercise, 33: 1176-1181.
Beiser TF, Lloyd DG, Ackland TR. (2003) Muscle activation strategies at the knee during running and cutting maneuvers. Medicine and Science in Sports and Exercise, 35: 119-127.
See comment in PubMed Commons below
Croisier JL, Ganteaume S, Binet J, Genty M, Ferret JM (2008). Strength imbalances and prevention of hamstring injury in professional soccer players: a prospective study. American Journal of Sports Medicine, 36(8):1469-75.
Escamilla RF, Macleod TD, Wilk KE, Paulos L, Andrews JR (2012) Anterior cruciate ligament strain and tensile forces for weight-bearing and non-weight-bearing exercises: a guide to exercise selection. Journal of Orthopaedic and Sports Physical Therapy, 42: 208-220.
Fatouros IG, Jamurtas AZ, Leontsini D, Kyriakos T, Aggelousis N, Kostopoulos N, Buckenmeyer P. (2000) Evaluation of plyometric exercise training, weight training, and their combination on vertical jump performance and leg strength. Journal of Strength and Conditioning Research 14: 470-476.
Kristianslund E, Faul O, Bahr R, Myklebust G, Krosshaug T. (2014) Sidestep cutting technique and knee abduction loading: implications for ACL prevention exercises. British Journal of Sports Medicine 48(9):779-83
Myer GD, Paterno MV, Ford KR, Hewett TE. (2008) Neuromuscular training techniques to target deficits before return to sport after anterior cruciate ligament reconstruction. Journal of Strength and Conditioning
Research, 0: 1-28 Myer GD, Ford KR, Hewett TE (2008). Tuck jump assessment for reducing anterior cruciate ligament injury risk. Athletic Therapy Today, 13: 39-44.
Myer GD, Martin L, Ford KR, Paterno MV, Schmitt LC, Heidt RS, Colosimo A, Hewett TE. (2012) No association of time from surgery with functional deficits in athletes after anterior cruciate ligament reconstruction: evidence for objective return-to-sport criteria. American Journal of Sports Medicine, 40: 2256-2263
Oberlander KD, Bruggemann GP, Hoher J, Karamanidis (2013) Altered landing mechanics in ACL-reconstructed patients. Medicine and Science in Sports and Exercise, 45: 506-513
Reid A, Birmingham TB, Stratford PW, Alcock, GK, Giffin RJ (2007) Hop testing provides a reliable and valid outcome measure during rehabilitation after anterior cruciate ligament reconstruction. Physical Therapy, 87: 337- 349
Wilk KE, Macrina LC, Cain EL, Dugas JR, Andrews JR. (2012) Recent Advances in the Rehabilitation of Anterior Cruciate Ligament Injuries. Journal of Orthopaedic & Sports Physical Therapy, 42: 153-171
Woo SLY, Abramowitch SD, Kilger R, Liang R. (2006) Biomechanics of knee ligaments: injury, healing, and repair. Journal of Biomechanics, 39: 1-20