Article type - Non technical. Audience- Athletes &Coaches. Read time 4mins
We have been hearing a lot about ACL injuries lately with the news that stars such as Carson Wentz (Philadelphia Eagles), DeShaun Watson(Houston Texans) Bernard Mendy (Manchester City), Chris Farrell (Munster & Ireland) and Bernard Brogan (Dublin) have all underwent reconstructions following ruptured ACL’s. In the NFL there are currently 17 players in ACL rehab , 5 players in the premier league and 17 AFL (australian rules) players. For supporters and team coaches, it often feels like it is a huge blow to lose their best players, knowing that it will be a long time before they see them on the pitch again.
Spare a thought for the athlete though. Most of the public really don’t understand why it is such a nasty injury. To return to high competitive levels of sport, the athlete will have to commit their life to rehabilitating their knee, spending untold hours in the gym and on the pitch to get the opportunity to play again. Its not unusual for early rehabilitation to require 4-5 sessions a week as they look to rebuild the muscles around their knee. This time is lonely, the athlete is away from their normal team environment and the work that has to be done, can be frustrating and sometimes even boring for them, especially as the gym visits add up. The reps need to be done!
The length of time out is generally somewhere between 6-12 months so if you add up those gym sessions you could be heading for 150 gym sessions in that time period! Have a think about that and your own activity over the past 8-9month period and now you can see where the work lies, and that is not even mentioning pitch sessions, recovery sessions or pool sessions!! Often there is other ligament and cartilage issues in addition to the torn ACL which will impact on outcomes. There is huge physical and mental resilience required to return to play (RTP).
The mental side of the injury cannot be overlooked. Alot depends on the athlete and their desire to return to sport. If there is a strong will to return, this will make all those sessions worthwhile, but with recreational athletes, this desire may not be present, which is why we see research papers with quite poor return to play numbers (at the same level). There are of course a range of other factors that will determine the eventual outcome, the athletes age, their socio-economic status and of course the degree of damage being one of the main issues.
The role that team mates, coaches, family and friends play in the rehab process can be huge. Although the athlete won’t want to be asked about their ACL injury every day. It can be nice to get words of encouragement from these people. Coaches especially have a major role in this, as athletes feel isolated from the group as seasons progress without them. Asking the athlete, what they are currently doing in their rehab and what are their short term goals can help focus athletes on the right things within their own rehab process.
*** The one question not to ask is “When will you be back?”- This can seem a far away prospect and often a frustrating question for ACL rehabbers. ****
So, back to thinking about the athlete…. The journey and what to expect.
Once that injury is confirmed (usually by MRI) an athletes mood is generally really poor. Although difficult to do, this is not a time to feel sorry for yourself! There can be big gains with good prehabiliation which will allow for a smoother transition through early stage rehab. Avoid comfort eating and binge drinking and instead use the time to get some quality strength work done, which will help reduce muscle wastage post surgery. Its also a time to do your research
- Talk to people that have been through the process.
- Discuss the graft type with your consultant (patella/hamstring) and which is the best option for you.
- Discuss your rehab plan with your physio
Immediately Post Surgery
The key thing immediately post surgery is regaining range of movement and reducing swelling. In the clinic we often get girls/guys coming into clinic like young foals released into the field for the first time - Mad for action!! The key thing here is to remember that doing too much here can negate progress later, especially if your knee starts swelling, or you get pain on your graft site (especially patella tendons). Often less is more here. Remember ACL rehab is a process and you won’t be able to sprint through the stages.
This is also the time @SPARC_Dublin where we sit down with our athletes and map out their journey in full. The surgery is complete and athletes are ready to embrace their own journey. Although there are healing times to adhere to, most of our rehab progression, is based on competency. Athletes earn the right to progress through each level by essentially meeting key performance indicators for their given level. Every athlete can then see their KPI’s in the short term and for the entire journey, making it easier for them to see the end goal and how they are going to get there.
Focussing on individual levels, ensures athletes focus on the most important aspects to their recovery while having the bigger picture.
12-14 week Testing
Many of our athletes will undergo testing at around 12-14 weeks post surgery. This testing involves neuromuscular and strength testing . It is definitely something we encourage athletes to do, as it gives them a snapshot of where they are at with their recovery. It is really common to see quadriceps strength and single leg control deficits at this stage. The key thing is not having pain at the end of this first 12 week phase. If athletes can achieve that, then considerable gains can be made in the second phase of rehab, when the graft and graft site are healing well and generally less irritable.
14-17 week post surgery -Running
This is often the time where athletes are most likely to get very frustrated. There has already been ALOT of strength work banked in the gym, and most athletes are getting fed up of gym work. It is generally the time just before getting running where this frustration is at its worst so expect it and know that once you have met your KPI’s for running, you will be back out there. Just remember, that its about getting back running with a normal running pattern, rather than limping around the field because you have returned before you were ready.
Week 20- 25 post surgery
Most guys will be running well by this stage and there is a tendency to want to push on. Impatience can be an issue and athletes often feel that they can jump in on the session. Remember that the running mechanics, the multidirectional running mechanics and all the other movement mechanics you undertake at this stage are vital parts of your rehab and keeping you on the pitch and most importantly performing well on your return to play. Once you rejoin team drills, the emphasis shifts from this to keeping up with play so its important you are ready for return to play. This is a shared decision between the athlete, their medical team and the coaching team.
26 week Testing
Often athletes will undertake a second battery of tests at this stage. In addition to the previous tests, multidirectional running and power measures may be assessed. Depending on how progress has been, this test reveals what fine tuning needs to be done. From experience, patella tendons tend to need to do more quad strength and hamstring grafts tend to need to do more hamstring strength. Power is often something that may only be entering the rehab process for a 4-6 week period at this stage so it may also be lacking. Using this test to ensure asymmetries and deficits are addressed will allow for better performance on return to the pitch.
Return to play
Returning to play is often a massive relief for athletes but at this stage the goalposts change. Regaining optimal performance becomes the main issue. The best way to achieve this, is by hitting all your KPI’s at each stage previous. If you are playing catch up and haven’t achieved this, you will be caught out here, as your body won’t be able to do the things you want it to do. Another massive drawback on return to play is further injury. Not so much with the ACL, it is often muscular injury. The key here is
- Increasing your load incrementally
- Ensure no compensatory patterns
- No asymmetries in muscle control or strength
- Graduated return to play and training
- Maintain strength work
- Regain conditioning prior to return to the main group
So to wrap up, you are going to have a wide range of different feelings during this process, ranging from feeling very low post injury, frustration, anxiety, pessimistic, optimistic, determined, lazy and almost everyone finishes with that elation when you get back to sport! Yes, it is a tough injury to obtain, but return to play is very achievable today, based on excellent surgical technique and rehabilaition methods. Yes, there is work involved but if you set your goals correctly at each stage, you will fly through it and yes it takes time to return to optimal performance but you can ensure this time is minimised by ensuring you are ticking off your KPI’s at each stage, putting you in the best position to get back to doing what you do best…. Playing!!!
Best of luck with everything, if you are unfortunate enough to find yourself with this injury. And if you know someone who has, you should now know some of what they are experiencing!
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