Athletes’ rehabilitation programs after anterior cruciate ligament reconstruction (ACLR) are diverse. The purpose of this study was to compare the evolution of postoperative rehabilitation protocol (standard and accelerated) after anterior cruciate ligament reconstruction. The subjects were two athletes, (football players), 27 and 28yearsoldmales with anterior cruciate ligament reconstruction with a hamstrings autograft, after knee injury. The rehabilitation protocol of both subjects started the day after surgery, 2 sessions per day, 6 days per week, for 6 months where one player was administered the
Keywords: Anterior cruciate ligamentaccelerated rehabilitationfootball playersspecific football exercisesrange of motion
Anterior cruciate ligament rupture is considered a serious injury in elite soccer and has significant impact to the player-sport performance and quality of life. In the past, the conservative rehabilitation process after cross-ligament reconstruction included prolonged immobilization and slow progression in returning to sports activity. At present, the rehabilitation programs are more aggressive and support the return of athletes to sports activities faster. It is important to consider the goals of the patient throughout the rehabilitation process in order to incorporate specific functional and sport-specific activities as appropriate (Eckenrode, Carey, Sennett, & Zgonis, 2017). The previously crossed ligament along with the thigh muscles and the other ligaments are designed to provide the necessary stability in the knee joint. The knee stability depends on the passive and active stability of the joint which involve the geometry of the articular surfaces, ligaments, meniscus and fibrous capsule and active stability is exerted by the muscles surrounding the knee during contraction: quadriceps, hamstrings, sartorius, gracilis and gastrocnemius (Dvorak et al 2009). Understanding ACLR loading mechanisms and knowing risk factors for the injury and mean off time after ACLR are essential information for the coach, the medical staff, the elite soccer players, the insurance and team managers (Schiffner et al.,2018). Wilk (2015) recommends streamlining rehabilitation programs for individuals which can return them to their preinjury activity levels, including implementation of thorough functional testing to determine whether a patient is ready to return to sports or strenuous post-ACLR activities.
Causes and mechanisms of ACL injury
The cross-ligament rupture is a serious injury commonly encountered in the football game that occurs as a result of direct contact with an opponent or when the player runs with directional changes, pivots to hit the ball, accelerates or stops suddenly. The most common ACL injury mechanism in male elite players is pressing, where a player makes a side-step cut during a defensive playing situation. In addition, landing awkwardly on one leg after a heading duel is another established non-contact injury mechanism (Waldén et al., 2015). The injury is characterized by joint instability that leads to decreased sports activity, unsatisfactory knee function, and poor knee-related quality of life in the short term (Spindler et al., 2008). Dvorak et al (2009) in the "Football Medicine Manual" considers that the most common causes occur during tackling: in the first instance, the impact hits the lateral side of the knee, forcing the knee into valgus and the tibia into external rotation, causing a sequence of injuries with progressive severity and the second important cause in tackling is an impact hitting the medial side of the knee, forcingthe knee into varus and the tibia into internal rotation. Various studies demonstrate that anterior translation of the tibia relative to the femur is the most important mechanism of ACL loading. Increased anterior shear forces at the knee due to a small knee flexion angle and increased compression forces on a posterior tilted tibial plateau are primary causes of anterior translation of the tibia relative to the femur (Dai et al., 2014).The same author considers the risk factors for knee injuries to include joint laxity, muscle weakness and fatigue, inadequate rehabilitation after previous injury, poor fitness and foul play with tackle on the lateral or medial side of the knee. Soccer players are at greatest risk for ACL injury when defending, especially when tackling the opponent in an attempt to win possession of the ball (Brophy et al.,2015).In addition to describing a mechanism listed above, 85% of patients will feel a pop at the time of injury and most will have significant swelling within two to three hours of injury (Rehabilitation Guide 2017). Management after ACL injury may involve an operation to replace the torn ligament with a graft in an attempt to reduce excess anterior tibial movement in the sagittal plane, and it gives the patient the chance to return to sporting activities (Kvist, 2004).The factors that can affect rehabilitation after reconstructive ACL surgery include concomitant injuries, timing of surgery, graft selection, concomitant surgeries, quality of rehabilitation, and the goals and desire of the athlete (Malempati et al., 2015).Understanding ACL loading mechanisms and risk factors for the injury is critical for designing effective prevention programs (Dai, et al., 2014). The same author considers warm-up programs for ACL injury prevention necessary because of its short training duration and capability of being incorporated into regular training.
The rehabilitation following the ACLR is crucial for the return of the player to the field at the same level as before the injury. Lai et al. (2017) in a systematic review and meta-analysis of five studies reported that postsurgery performance was unchanged (Erickson et al., 2013; Erikson et al., 2014) compared with preinjury performance, while other studies reported that performance deteriorated after surgery (Fabricant et al., 2015; Harris et al., 2013; Sikka et al., 2016).
Typical post-operative ACLR and rehabilitation protocols stages include: an early post-operative phase, which focuses on addressing knee range of motion (ROM) deficits, initiating knee strength and control, minimizing pain and effusion, and normalizing gait; a strengthening and neuromuscular control phase, which includes the progression of lower extremity functional strength, and enhancement of balance and neuromuscular control; an advanced strengthening phase, which progresses the patient into plyometrics, agility activities, running and early sport-specific training; and with a final phase focusing on continued strengthening and neuromuscular control with emphasis towards return to sport activities (Eckenrode et al., 2017).
The athletes’ rehabilitation programs after ACLR follow three phases of progression: basic, intermediate and advanced. The first phase assumes the recovery to basic fundamental movement. The key to bridging the gap between rehabilitation and sports application is to return to basic fundamental movement skills and addresses the physiological responses of pain, swelling, range of motion and basic strength during the early phases of healing (Rehabilitation Guide 2017).
The second phase assumes recovery of biomotor patterns and continued improved range of motion (full extension and full flexion), proprioception, flexibility, gradual strengthening of the hamstring and quadriceps muscles, knee stabilization and cardiovascular fitness before advanced athletic movements can be achieved.
Phase three assumes specific training and reconditioning to return to sports competition, optimized plyometrics training, specific neuromuscular control, improved specific sport skills (speed, agility, coordination, strength) and specific conditioning, and returning gradually to sports practice (individual and team) with minimal risk of re-injury. The rehabilitation programs after ACLR are diverse and transforming. The options for rehabilitation include accelerated vs. conservative, closed vs. open kinetic chain and other techniques involving bracing, home-based rehabilitation, and neuromuscular training (Grant, 2013). Previously, conservative rehabilitation with limitation of range-of-motion (ROM), delayed weight bearing with full weight bearing at 8–10 weeks and returning to sports after 9–12 months has been the norm (Kvist, 2004). In contrast to this, Dvorak, et al. (2009) in the "Football Medicine Manual" claimed that with conservative treatment of isolated, partial or complete tears, the return to football training and matches may be quite fast if the ROM and muscular strength are restored and can be attempted after eight to 12 weeks. The accelerated protocols with immediate training of ROM and weight bearing allow the return to sports within 4–6 months (Kvist, 2004). Professional football needs accelerated protocols with immediate training of ROM, strength and muscle endurance and returning to the field as soon as possible. In the rehabilitation protocols, the full ROM, limb strength symmetry, and neuromuscular control are important for an athlete to safely and effectively return to sports (Malempati et al., 2015).
Return to Sports
It is important to realize that return to sports is not based on a specific timeline; it is based on the individual athlete’s ability to meet physical performance criteria, mental readiness, age, type of sport and the player position (Rehabilitation Guide, 2017). Return to sports includes return to football practice (individual and team) and full game with minimal risk of re-injury.
The return to sports should be based first of all on a series of intrinsic factors, that depend exclusively on the patient himself such as genetics, lesion type, anatomical features, rehabilitation protocols, motivation, psychological attitude and extrinsic factors type of graft, surgical technique, rehabilitation phases, biological support (Czuppon et al., 2014; Zaffagnini et al., 2015). Recent research has suggested that psychological factors may be important influences on returning to sports and recreation after athletic injury but cautioned that because there are few studies examining the relationship between psychological factors and returning to sports and recreation, more research is needed to facilitate more definitive conclusions (Ardern et al., 2014). Extrinsic factors are influenced by many personal and contextual factors and have been investigated by numerous studies (Engelman et al., 2014; Saka, 2014).
Tjong, et al. (2014) identified fear of reinjury and individual personality’s priority as reasons for those athletes who do not choose to return to their pre-injury level of activity. Several psychological scales have been reported to predict the ability to return to sports; this is confirmed by evidence that the reason for abandoning sports may not be related to objective knee problems but rather to psychological issues such as fear of re-injury, family or personal problems, or other factors (Ardern et al., 2014). Rambaud et al. (2017) assume that many factors have been implicated in reinjury risk, including gender (Allen et al., 2016), age (Webster et al., 2014; Kamien et al., 2013), activity level (Borchers, Pedroza & Kaeding, 2009), graft type (Gifstad, 2014) or duration after surgery (Maletis et al., 2013). Clinical evidence indicates that the highest risk of ACL reruptures is within the first two years after reconstruction, especially in young high-level athletes (Nagelli & Hewett, 2017). The same authors assert that the incidence of ACL reruptures significantly decreases if athletes delayed their return to high-level activity until 2 years after ACLR. In an ample review, Kvist (2004) presented factors and criteria for safe returning to sports after ACLR, as presented in Table
For surgically-treated players, the period of prehabilitation prior to ACLR should be used to inform the player in detail about the procedure and to ensure that he has realistic expectations regarding the recovery of his knee function (Dvorak et al., 2009). First of all we must clarify what “return to sports” means because the term has different interpretations for different people. In patients aiming to return to sports, the rehabilitation program must continue until this is possible (Rambaud et al., 2017). To consider ACL rehabilitation successful, the patient should be able to return to the same level of sporting activity as before the injury (Lynch et al., 2015). For this purpose, the accelerated rehabilitation after surgery is necessary and helps the players to return to the football career at the same competitive level as prior to the injury. There is controversy about the optimal point of time to allow the athlete to return to sports especially on a competitive level. In most studies
a postoperative period of six months was suggested as to be sufficient where the athlete should refrain from her or his original activity (Barber-Westin et al., 2011). In football, most players return to training and matches after six to nine months or much earlier; 77 days after surgery (Roi et al., 2005). In a systematic review, Lai et al. (2017) identified four studies which mentions that on average, soccer players returned to sports between 6 and10.2 months postoperatively (Erickson et al. 2013); Howard et al. (2016); Zaffagnini et al. (2014). An analysis of Union of European Football Associations (UEFA) elite male soccer players showed a mean injury lay-off until return to unrestricted soccer practice of 202 ± 69 days for 43 European players and 203 ± 70 days for 20 Swedish players (Waldén et al., 2011). Schiffner et al. (2018) found a mean injury lay-off of 244 (range 118–604) days (8.1 months) until return to unrestricted soccer practice after total ACLR.
Van Grinsven et al. (2010) in a systematic review recommended the following criteria for return-to-sports in 6 months: full ROM, 85% or greater on strength (quadriceps and hamstrings) and single-leg hop tests compared with the opposite leg, less than 15% deficit on hamstring-quadriceps strength ratio, no pain or swelling with sport-specific activities, and a stable knee in active situations. In a soccer-specific rehabilitation program, it is important to know the physical demands of the football game and the performance level which the player needs to attain.
To attain this goal, close cooperation between the patient, physiotherapist, surgeon, coach and family athlete is necessary (Damian et al., 2018).
It is important to realize that return to sports is not based on a specific timeline, but on the individual athlete’s ability to meet physical performance criteria, mental readiness, age, type of sports and the position he is playing (Rehabilitation Guide, 2017).
What is the difference in the evolution of postoperative rehabilitation protocols (standard and accelerated) after anterior cruciate ligament reconstruction?
Purpose of the Study
The purpose of this study was to compare the evolution of postoperative rehabilitation protocols (standard and accelerated) after anterior cruciate ligament reconstruction.
The subjects were two athletes, (football players), 27 and 28year old males with ACLR with a hamstrings autograft. The rehabilitation protocols of both subjects started a next day after surgery, comprising 2 sessions a day, 6 days a week, for 6 months. Each session lasted 90 minutes. The players were observed and evaluated periodically and the results were compared.
The subject who followed the accelerated protocol realized a better (LEFS) score than the subject who followed the standard protocol and returned to competitive level after 6 months. The rehabilitation followed without complications; both players showed a strong determination to return to their football career at the same level as before the injury. The accelerated program supported the player to play first his game 6 months after surgery. The player who followed the standard program played the first match 7 months after surgery. Codorean, Codorean & Cojocaru (2016) argue that for an athlete to be competitive after ACLR, it is imperative to regain muscle strength and neuromuscular control of the affected lower limb, and maintain static stability of the joint. The muscular strength was improved with isometric, isotonic, and isokinetic training.
To eliminate edema and pain, ice was applied for 20 minutes 3 times a day, on the raised leg with extension knee. Improvement of ROM was achieved by activating the quadriceps muscle with flexion and extension (flexion 3x20; extension 3x20), voluntary quadriceps contractions (3x20) and walking reductive exercises (3x20 meters).Stretching exercises are necessary for maintaining range of motion in all joints. They improve the muscle-tendon and ligament elasticity, reduce the risk of reactivation, and help improve postural stability and equilibrium. Some core exercises for the abdominal part, lower back and muscles, important for ensuring correct body posture and reeducation of walking were used in the rehabilitation program. Strong core body musculature is important in specific football motion. Codorean, et al. (2016) claim that core exercises is the foundation in daily life activities and in athletic movements. In first week, the LEFS score was 15 points. After 4 week of exercises comprising flexibility, stability and walking re-education, cardiovascular fitness, quadriceps activation, patellar mobilizations, the score increased to 39 points.
De Carlo (1992) asserts that patients who started weight bearing or gained range of motion earlier than advised had stronger, more functional knees at the completion of the rehabilitation. At this stage, we continued to improve the ROM through flexion and extension with weighs of 1kg each foot (flexion 3x20; extension 3x20) and the resistance band exercises (4x20 flexion-extension). Maintaining cardiorespiratory fitness through endurance training: bike (3x5 minutes 60% heart rate), stepper exercises (level 6) and band running (2x5 minutes) also helped to improve ROM and progress to a new stage. Improving muscle strength was accomplished with isotonic machines (leg extension, leg press, leg curl, adductors, abductors, gluteus and body weight exercises: squats, split squat, Bulgarian squat) in agreement with Codorean, et al. (2016) .Significant deficits in quadriceps strength are evident after ACLR (Kline, et al. 2015). According to Malempati et al. (2015) the quadriceps and hamstring musculature must be strengthened to achieve muscular balance in the affected extremity. Swimming exercises in the pool (crawl style) to develop the resistance of the quadriceps muscle and the muscle-tendon and ligament elasticity were done. Proprioception exercises and static balance exercises were done to improve the static balance. In week 5 the LEFS was 42 points. After 11 weeks of exercises: ROM (full extension and full flexion), flexibility, strength muscle, knee stabilization and cardiovascular fitness, the score increased 60 points.
In week 17, the LEFS score was 62 points. After 11 weeks of exercises: continued improvement of ROM (full extension and flexion), improved specific neuromuscular control and stability ligament (proprioception and static balance exercises, bosu balance, semi-squads), agility workout, coordination, strength and cardiovascular fitness, the score increased to 75 points. This phase represents the final rehabilitation of the player and return to competition level sports. At this stage, we continued improvement of general muscle strength through isotonic machines exercises and pliometric exercises. According to Negrea, Negrea & Teodor (2010) pliometrics exercises are scheduled after warm-up. Cardio respiratory capacity was maintained through endurance exercises (bike 2x7 minutes 60% heart rate, aerobic run 2x20 minutes and aerobic-anaerobic run 12 minutes) and agility exercises (straight line, lateral, diagonal, forward: 4x4,6,8, 12 meters). The stretching and coordination exercises used were aimed to improve the stability, elasticity of the ligament and prevent the risk of recurrence.
The accelerated rehabilitation program, which allows patients to achieve full extension of the knee early in the postoperative period, is now a widely practiced rehabilitation program An KO (2017). In first week, the LEFS score was 14 points. After 4 week of exercises: quadriceps isometrics, bike pendulums, semi-squat (30°),flexibility, stability and walking reeducation, abduction/adduction exercises, core exercises, quadriceps activation, patellar mobilizations, the score increased to 38 points.
In this phase, isotonic machines (leg extension, isometric, eccentric, concentric), leg press (isometric, eccentric, concentric), leg curl, adductors, abductors, gluteus and body weight exercises: squats, split squat, Bulgarian squat, step up, lateral lunge walk, forward lunge walk, calf raises (concentric and eccentric single leg), intrarotators were applied (Codorean et al 2016). Malempati, et al. (2015) advised that neuromuscular training should continue to promote neuromuscular control and proprioception.Warm-up programs for ACL injury prevention have received great interest recently because of its short training duration and capability of being incorporated into regular training (Hewett et al. 1999).In week 5, LEFS score was 40 points. After 11 weeks of exercises: range of motion (full extension and full flexion), flexibility, strength muscle, knee stabilization and cardiovascular fitness, the score increased 61 points.
Specific neuromuscular training and football conditioning are important aspects of this phase. Hewett et al. (1999) investigated the effects of comprehensive neuromuscular training on non-contact ACL injury rates in high school soccer, volleyball, and basketball players. The study concluded that the training program significantly reduced the ACL injury rate. In week 17, the LEFS score was 63 points. After 7 weeks of exercises: plyometrics training, specific neuromuscular control, football skills (speed, agility, coordination, strength), specific football conditioning, football practice (individual and team football exercises: passing short distances, sub-maximal shooting, dribbling, running whit the ball), the score increased at 80 points. Proprioception continued the improvement with specific football exercises (forward and lateral hop and maintain stability for 3 seconds on landing). Risberg et al. (2009) concluded that the combination of strength training and neuromuscular exercises was required to achieve the best outcomes, including the patient’s perception of knee function and knee performance on strength and hop tests. Cardiovascular fitness has training with specific football running with turns 90,180 and 360°, speed (running with change of direction 6x4,6,8,12 m, carioca,), and agility (lateral, diagonal, forward drills).The agility part of the program incorporates sport-specific activities that reinforce safe movement patterns and encourage the use of musculature that reinforces the anterior cruciate ligament (Dvorak et al., 2009). Agility was improved with agility training drills but also by improving the specific individual fitness elements of speed, balance, power and coordination. Negrea et al. (2015) believes that the development of force is necessary to perform the tasks specific to the game and to increase the performance of athletes to optimal level. Maintaining an optimal level of cardio respiratory fitness throughout the rehabilitation program has facilitated the achievement of the specific objectives of each stage and the faster passage to the specific training of the football game. This phase represents the final rehabilitation of the player and return to the competition.
Return to optimal level play should require an individualized progression through objective phases supervised by a kinetotherapist. Therefore patient-tailored rehabilitation protocol shave been developed, structured in progressive phases, and specific goals rather than temporal criteria must be met in order to progress from one phase to the next, involving on-field rehabilitation with sport-specific movements and actions (Della Villa et al., 2012). Zaffagnini et al. (2015) consider it relevant to apply patient-tailored rehabilitation protocols and return-to-sport criteria, based on individual characteristics.
The results of the study show that specific rehabilitation for football players, the accelerated protocol (B) may provide a complete and accelerated functional recovery. The player who underwent this protocol achieved better results after the accelerated rehabilitation program in contrast to the player who followed the standard protocol (A). To accelerate the rehabilitation program, we must be include general goals (range of motion, flexibility, normalizing walking, balance strength and endurance muscle, proprioception, cardio respiratory fitness) and specific goals (plyometrics training, specific neuromuscular control, improve football skills: speed, agility, coordination, strength and specific football conditioning, return to full football practice: individual and team football exercises). The specific football goals are necessary to speed up recovery and minimizing risk of reinjury. Maintaining an optimal level of cardio respiratory fitness throughout the rehabilitation program can facilitate the achievement of the specific objectives of each stage and the faster passage to the training specific to the sport practiced. Furthermore, the protocol rehabilitation must begin on the first day after surgery.
This study is important because it provides empirical evidence for a rehabilitation protocol after anterior cruciate ligament (ACL) reconstruction which can safely provide a complete and accelerated functional recovery. In sports performance, this aspect of recovery and rehabilitation is of utmost significance for the athlete and the sport he/she represents.
The authors are grateful to the study participants and Ovidius Clinical Hospital Constanta (OCH) staff.
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28 June 2018
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Sports, sport science, physical education, dance education
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Mirela, D., Cosmin, D., Antoanela, O., & Dragos, T. (2018). Accelerated Rehabilitation For Football Players Following Acl Reconstruction. In E. Lupu, G. Niculescu, & E. Sabău (Eds.), Sport, Education and Psychology - icSEP 2018, vol 42. European Proceedings of Social and Behavioural Sciences (pp. 66-79). Future Academy. https://doi.org/10.15405/epsbs.2018.06.02.8