A 21ST CENTURY APPROACH TO TESTING, REHABILITATION AND RECONDITIONING!
Albert Einstein famously once said that “the definition of insanity is doing the same thing over and over again and expecting a different result.” Controversially, this same thinking could be applied to the ACL return to sport literature. In the last 40 years, the world has evolved and advancements in technology have been astronomical. However, we are still today predominantly using testing protocols that were developed in the 1980’s (originally to identify functional abnormalities) as our method to determine readiness to return to sport.
Considering the current evidence, it appears that at best, our ability to determine successful outcomes following ACL reconstruction is equivocal. Furthermore, re-rupture / injury rates remain high; thus, we need to question if current recommendations are suitable to prepare athletes to ‘return to performance’. Now is the time to change as we are still a long way from understanding pertinent factors associated with successful patient outcomes. To do this we need to think more critically and develop strategies to effectively ‘bridge the gap’ between rehabilitation and return to performance.
As a start point, we need to more fully appreciate that return to sport is a journey and should not be defined by a single or selected group of tests. Specifically, optimal reconditioning after such a serious and traumatic injury requires learning/re-learning of skills, physical capacity development, exposure and re-integration of cognitive function by progressing from control to chaos, graded progression and gradual accumulation of both enough load (volume and intensity) and representative load (considering physical and cognitive sport demands), while integrating regular and precise monitoring of adaptation. That is the focus of this special edition, with novel and outstanding content provided from each one of our invited experts in their respective fields.
The athletes journey begins on day 1, and while initially this may mean training around the injury, we must not forget that an athlete should always remain an athlete. We of course should respect the principles of protection, repair and appropriate joint loading, but we should also encourage and promote a variety of means to develop / maintain athleticism. Our approach needs to be sensible, diligent and methodical. However, we shouldn’t be scared, over-cautious, afraid to load or wait too long before applying an appropriate stimulus. Remember we are aiming to return an athlete to a state in which they are ready to re-perform and not just focusing on an injury. While important, it is not just about the knee; we also need to consider global athlete preparation. Thus, we could consider a paradigm shift, in which 9 months (or whatever the required timeframe is for return to sport) is seen as an opportunity to grow and develop.
Finally, it is important to recognize the significance of a multidisciplinary team in the planning and implementation of effective return to sport conditioning. Not to underplay the importance of the medical team, but sports science should also be an integral part of the return to sport puzzle, whereby a collective range of skill sets are utilized to most effectively design and deliver a high-performance reconditioning plan for our athletic populations. We hope this special edition provides some unique insights into a modern approach for assessing and reconditioning athletes as they aim to return to performance following ACL injury and surgical reconstruction.
Paul Read PhD
Clinical research Scientist
Aspetar – Orthopedic and Sports Medicine Hospital
Header image by Jon Candy (Cropped)