CONTENT AND CONSIDERATIONS
– Written by Konstantinos Defteraios Thedosia Palli, Qatar
Athletes who sustain an injury to their anterior cruciate ligament (ACL) have high expectations (88%) after following ACL reconstruction (ACLR) to return to their pre-injury level of sports, but only 55% get back to that same level4,6,7. Despite the volume of research in the areas of ACL injury prevention, surgical, nonsurgical management and return to participation, primary and secondary injuries continue to occur at an alarming rate, at all participation levels8-9.
One part of the return-to-sport (RTS) program after ACL reconstruction that has received less attention is on-field rehabilitation: the period when the athlete is transitioning from gym-based rehabilitation to the competitive team environment2,3,13. On Field Rehabilitation is considered an important element due to the ecological validity offered by using various training stimuli to stimulate tissue loading in a way which more similar to that experienced during training and competition13. A vital component of this framework is the safe and effective return of players to their preinjury chronic running load, whilst progressively integrating the qualitative aspects of movement, football-specific skills, and cognitive stresses integral to competitive match-play14,10,11.
Sports Specific on-field rehabilitation is an essential element for athletes to test their progression, build confidence and improve performance after the ACL reconstruction. It enhances their readiness to return to training by recreating the chaotic environment of their sport with regards to the physical, technical, and neurocognitive demands of the sport while building up their exposure running volume and intensities they will be transitioning back to. This process is crucial to bridge the gap for a safe resumption of full-team training, then gradual transition to full competition thereby reducing the risk of reinjury and optimizing performance.
Successful on-field rehabilitation is achieved with emphasis on rehabilitation considerations and sport-specific performance needs. Consideration of the late phase rehabilitation principles on one side (such as neuromuscular control and movement quality) and of training and match demands on the other hand is important to ensure that an athlete is well prepared for RTS2,5. Buckthorpe et al, suggest considering this complicated last phase of rehabilitation as comprising 4 pillars: 1 restoring movement quality, 2 physical conditioning, 3 restoring sport-specific skills, and 4 progressively developing chronic training load1,2.
Following this structure the sports specific football program in Aspetar comprises 5 field-based training stages:
1. linear movement,
2. multidirectional movement,
3. soccer-specific technical skills,
4. soccer-specific movement, and
5. practice simulation.
At the conclusion of these stages the athlete will then follow a progressive return to team practice and gradual return to competitive match play. This process allows the player to focus on regaining football-specific movement with physical, technical, and tactical performance while developing psychological readiness to perform2,3.
Patients are referred by their treating physiotherapist to commence Aspetar’s sports specific on-field rehabilitation program once they have met the entry criteria (Table 1) and completed an assessment by the sports rehabilitation physiotherapist. Criteria for progression through the sports specific program include pain free participation, no flare-up after a session, athlete confidence and execution with each phase of drills. When athletes complete the 3rd stage of the protocol they are comprehensively re-assessed, including biomechanical analyses of vertical jumps, single leg hop for distance, 90˚ direction change, and a cardiovascular endurance test (Yo-Yo) to chart progress and identify any residual deficits which can be targeted and addressed through the final two stages. On completion of the 5th and final stage, the athlete returns to the assessment laboratory for a discharge testing. Should they successfully meet all discharge criteria for all these tests, they are then referred back to the treating surgeon for their final review and possible clearance for return to unrestricted training. Upon returning to training, the GPS data from the rehabilitation sessions are provided to the club’s medical and physical conditioning teams to assist with sensible return to normal training loads given the individual’s training history.
CONCLUSION
Sports-specific on-field rehabilitation plays a crucial role in an athlete’s journey to recover from ACL reconstruction and return to their pre-injury level of sports participation. The process involves mimicking the chaotic on-field environment to build confidence and improve performance. The rehabilitation process which started with slow, controlled in-plane movements culminates with the on-field stage which progressively exposes athletes to out-of-plane movements in a less controlled competitive environment. As such, on-field rehabilitation offers an essential addition to the rehabilitation program that aligns rehabilitation principles with sport-specific performance needs, facilitating a safe and effective return to play. By focusing on movement quality, physical conditioning, sport-specific skills, and progressive development of chronic training load, athletes are mentally and physically preparing for their return to full team training and then competitive match play. The incorporation of the five stages of on-field rehabilitation helps ensure a well-structured and successful return-to-sport plan for athletes following ACL reconstruction.
Konstantinos Defteraios PT
Physiotherapist
Theodosia Palli PT
Physiotherapist
Aspetar Orthopedic and Sports Medicine Hospital
Doha, Qatar
Contact: Konstantinos.Defteraios@aspetar.com
References
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2. Matthew Buckthrope, Francesco Della Villa, Stefano Della Villa, Giulio Sergio Roi. On-field Rehabilitation Part 1: 4 Pillars of High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restoring Sport-Specific Skills, and Progressively Developing Chronic Training Load. J Orthop Sports Phys Ther. 2019 Aug;49(8):565-569.
3. Matthew Buckthorpe, Francesco Della Villa, Stefano Della Villa, Giulio Sergio Roi. On-field Rehabilitation Part 2: A 5-Stage Program for the Soccer Player Focused on Linear Movements, Multidirectional Movements, Soccer-Specific Skills, Soccer-Specific Movements, and Modified Practice. J Orthop Sports Phys Ther. 2019 Aug;49(8):570-575.
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