ACLR Recovery

This post will look at some of the issues concerned with anterior cruciate ligament reconstruction (ACLR) surgery. Injuries of the anterior cruciate ligament are common in sports. These injuries have a high impact not only on the personal life of the individual, but also on their career because they have to undertake a long recovery period (Brophy et al., 2009). ACLR surgery remains the standard approach for athletes who aim to return to high-level sporting activities as soon as possible (Hewett et al., 2013)

Mechanically, anterior cruciate ligament injury occurs when an excessive tension force is applied on the ligament from contact. A non-contact anterior cruciate ligament injury occurs when a person generates greater force or movements at the knee and applies excessive loading on the ligament (Yu & Garrett, 2007).

Previous football studies have reported that the contact element in anterior cruciate ligament injuries is responsible for 16-22% of the total injuries sustained (Faunø & Wulff Jakobsen, 2006; Rochcongar et al., 2009). This data is consistent with later research by who advocates a similar figure of 15%. According to these data figures Walden et al. (2015) reports 85% of injuries are caused by non-contact. Their research indicates three distinct predominant mechanisms, which are: pressing followed by re-gaining balance, re-gaining balances after kicking, and landing after heading.

When patients are recovering from reconstruction surgery of the anterior cruciate ligament the process depends on the type of reconstruction surgery, which has occurred, in terms of anatomical graft (patellar or hamstring) and fixation strength (single / doubled blinded). Research by Webster et al. (2014) indicates that athletes returning to cutting/pivoting sports increased the odds of graft rupture by a factor of 5.

Secondary injuries are also a large factor to consider in professional sport. Paterno et al. (2014) report 29.5% of athletes suffered a second anterior cruciate ligament injury and six times greater than the control subjects in their 24-month study.

The time between the injury and the surgery may have a factor on the success of returning to sport to the previous level. However, research by Frobell et al. (2013) shows that in this time period there is no significant difference in the time frame between injury and surgery. Furthermore, returning to sport from ACLR is no guarantee of a return. MOON cohort reports that 30% of cases were unable to return to playing sport at all. Ardern et al. (2011) conducted meta-analysis which suggests that 63% return to pre-injury levels of sports, and 44% to competitive sports.

The videos below show a cross section of some of the recovery exercises and drills, which were used in returning the client back to competitive sport. These videos are a snap shot of a recovery period, which lasted a number of months.

References

Ardern, C.L., Webster, K.E., Taylor, N.F. & Feller, J.A. (2011) Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. British Journal of Sports Medicine. Vol. 45, No. 7: 596–606. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21398310\nhttp://www.scopus.com/inward/record.url?eid=2-s2.0-79955880518&partnerID=40&md5=2dd70cf46204a87edc216f6fb40b9b47.

Brophy, R.H., Wright, R.W. & Matava, M.J. (2009) Cost analysis of converting from single-bundle to double-bundle anterior cruciate ligament reconstruction. The American journal of sports medicine, 37(4), pp.683–7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19204364 [Accessed March 9, 2013].ngle-bu. The American Journal of Sports Medicine. Vol. 37, No. 4: 683–7. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19204364.

Faunø, P. & Wulff Jakobsen, B. (2006) Mechanism of anterior cruciate ligament injuries in soccer. International Journal of Sports Medicine. Vol. 27: 75–79.

Frobell, R., Roos, H., Roos, E., Roemer, F., Ranstam, J. & Lohmander, L. (2013) Evidence-Based Orthopaedics: Rehabilitation Plus Early ACL Reconstruction and Rehabilitation Plus Delayed Reconstruction Were Similar at 5 Years. The Journal of Bone and Joint Surgery. American Volume. Vol. 95-A: 1516.

Hewett, T.E., Di Stasi, S.L. & Myer, G.D. (2013) Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine. Vol. 41, No. 1: 216–24. [Online] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3592333&tool=pmcentrez&rendertype=abstract.

Paterno, M. V, Rauh, M.J., Schmitt, L.C., Ford, K.R. & Hewett, T.E. (2014) Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. The American Journal of Sports Medicine. Vol. 42, No. 7: 1567–73. [Online] Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4205204&tool=pmcentrez&rendertype=abstract.

Rochcongar, P., Laboute, E., Jan, J. & Carling, C. (2009) Ruptures of the anterior cruciate ligament in soccer. International Journal of Sports Medicine. Vol. 30, No. 5: 372–378.

Walden, M., Krosshaug, T., Bjorneboe, J., Andersen, T.E., Faul, O. & Hagglund, M. (2015) Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases. British Journal of Sports Medicine. Vol. 49: 1452-1460. [Online] Available from: http://bjsm.bmj.com/cgi/doi/10.1136/bjsports-2014-094573.

Webster, K.E., Feller, J. a, Leigh, W.B. & Richmond, A.K. (2014) Younger patients are at increased risk for graft rupture and contralateral injury after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine. Vol. 42, No. 3: 641–7. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24451111.

Yu, B. & Garrett, W.E. (2007) Mechanisms of non-contact ACL injuries. Br J Sports Med. Vol. 41: 47–51.

Here is the references list from the videos:

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Chmielewski. T.L., Myer. G.D., K.D. (2006) Plyometric exercise in the rehabilitation of athletes: physiological responses and clinical application. Journal of Orthopedic Sports Physical Therapy. Vol. 36: 308–319.

Cronin, J. & Sleivert, G. (2005) Challenges in understanding the influence of maximal power training on improving athletic performance. Sports Medicine. Vol. 35, No. 3: 213–234.

de Villarreal, E.S.S., González-Badillo, J.J. & Izquierdo, M. (2008) Low and moderate plyometric training frequency produces greater jumping and sprinting gains compared with high frequency. Journal of Strength and Conditioning Research / National Strength & Conditioning Association. Vol. 22, No. 3: 715–725.

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García-Pinillos, F., Ruiz-Ariza, A., Moreno del Castillo, R. & Latorre-Román, P.Á. (2015) Impact of limited hamstring flexibility on vertical jump, kicking speed, sprint, and agility in young football players. Journal of Sports Sciences. Vol. 33, No. 12: 1293–7. [Online] Available from: http://www.ncbi.nlm.nih.gov/pubmed/25761523.

Helgerud, J., Rodas, G., Kemi, O.J. & Hoff, J. (2011) Strength and endurance in elite football players. International Journal of Sports Medicine. Vol. 32, No. 9: 677–682.

Lehance, C., Binet, J., Bury, T. & Croisier, J.L. (2009) Muscular strength, functional performances and injury risk in professional and junior elite soccer players. Scandinavian Journal of Medicine and Science in Sports. Vol. 19, No. 2: 243–251.

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Walden, M., Krosshaug, T., Bjorneboe, J., Andersen, T.E., Faul, O. & Hagglund, M. (2015) Three distinct mechanisms predominate in non-contact anterior cruciate ligament injuries in male professional football players: a systematic video analysis of 39 cases. British Journal of Sports Medicine: 1–10. [Online] Available from: http://bjsm.bmj.com/cgi/doi/10.1136/bjsports-2014-094573.

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This upcoming conference maybe one not to miss. I will review the three days after I been and absorbed the latest and most recent updates in the return to play field.

 

This post is a repost from the twiter name ‘The Sports Physio’ aka Adam Meakins who presently is an Extended Scope Practitioner, in the NHS, however, was a former lecturer, who’s friend Tom Goom produced a guest blog on his website. So here it is below taken from the Arsenal SEMS conference 2016. This may be of interest to some of you.

Guest blogs are a bit like buses… You can wait six weeks for one, then two turn up together. Today’s guest blog is from a good friend of ‘The Sports Physio’ Tom Goom aka ‘The Running Physio’. Now as much as I think Tom is a legend in his own right, in his blog Tom talks about another legend and a personal hero of mine from Arsenal FC, I wont spoil the surprise instead I will let Tom take it away…

Today’s Arsenal SEMS Conference started with a surprise speaker. The room hushed and he had everyone’s attention in a split second. But this speaker wasn’t one of the multi-published, hugely impressive lecturers on the bill. He didn’t hone his skills in the clinic or the lab but on the football pitch. Despite this his insights were as valuable as any paper but then, could you expect anything less than excellence from Thierry Henry?!..

Dr Gary O’Driscoll, Arsenal’s head doctor, skillfully interviewed the Arsenal legend and his answers highlight some key issues working in elite sport. Apologies if I paraphrase Thierry’s answers a little I couldn’t write them down quickly enough!…

Pain may be part of the Process

A hugely revealing comment from Thierry was, “most of the time I was in pain.“ I was surprised to hear an elite player, so capable with a football, spent much of his career playing through pain. Later in the day England Rugby Team Doctor Nigel Jones highlighted a similar issue, “all of our players play with an injury.”

The training loads and demands of competition at the highest level make pain and injury a likely consequence. The question is, as highlighted by Nigel Jones, is the pain sufficient to prevent play? Our role as physios is to help manage this pain and help the patient understand it. Appropriate loading and adequate recovery are key. Thierry commented on this, “rest is very important…don’t underestimate sleeping for recovery.” Evidence suggests sleep is essential for performance, healing and pain.

Magic or Mental?

Thierry also made a point I’m sure Adam will enjoy, “I don’t believe in magic. I think you need to do everything you can in order to perform.” A point further emphasised by the excellent Karim Khan who warned against giving in to quick fixes that, in reality, fix very little!

Image source

Achilles issues troubled Thierry from around 2004 until the end of his career. Their effect was more than just physical. It left him unsure whether he’d be able to perform and concerned he’d be unable to help his teammates.He conceded, “The mental part is huge” and admitted to worrying about how it might affect him after his football career. We can’t underestimate the psychological load elite sport places on an athlete and how this increases when struggling with an injury. Even the very best will worry and ask ‘what if?’. We need to consider the psychological impact and foster a positive perception of return to sport with the athlete in charge. Clare Ardern’sexcellent work show’s how important this is for return to play after injury.

Take Responsibility!

Thierry’s final point highlights how the patient should be central to everything and must take responsibility, “A player needs to take care of himself… I was on a mission to make sure I could perform for the team.” We need to support an athlete’s autonomy, educate and empower them to make informed choices. Ultimately though the athlete needs to be in the driving seat.

As a lifelong Arsenal fan is was an inspiring and illuminating interview and it demonstrates just how important it is that we listen to our patients. They don’t have to be footballing legends to teach us a thing or two!

Tom

Follow Tom Goom on Twitter here and find out more about his Running Repairs workshops here which I can vouch for as having done it myself as being totally awsome. Adam