Even with the best programming for risk reduction, ACL injuries still happen. And when they do, it is the responsibility of the therapist or performance coach to rebuild the athlete’s confidence as well as their strength.
Quite often, there is a lack of confidence or the physiological factor that contributes to the athlete’s ability to return to sport (Ardern, 2011). According to the research, many ACL injuries stem from factors that involve strength imbalances, inefficient propreoceptive feedback and unsafe use of momentum in deceleration (positioning and movement pattern synchronization). Many times athletes come out of their rehabilitation program still lacking the confidence and fitness to perform up to their pre-injury level. But this is avoidable… Below is a chart of one athlete’s testing as she returned to train with her team after an ACL surgery (taken from the SoccerFIT Game Speed Level 1 Test). Her tests are compared to the best scores in her age group as well as the average scores in her age group within each category.
A recent study on the return to activity rate shows that although sixty-seven percent of patients attempted some form of sports activity, by 12 months postoperatively only 33% returned to competitive sport (Ardern 2011). These numbers might lead one to believe that there is something missing in the rehabilitative process. The authors of this study suggest, “The relatively low rate of return to competitive sport despite the high rates of successful outcome in terms of knee impairment-based function suggests that other factors such as psychological factors may be contributing to return-to-sport outcomes.”
The Return to Confidence Protocol is a relatively new program we have designed to parallel to the patient/client’s physical therapy program in order to address the fitness and athletic confidence factors that are currently lacking in most physical therapy programs. To achieve this goal, this protocol will focus on several critical areas:
- Movement Efficiency (Confidence and Coordination)
- Strength and Power (Acceleration & Deceleration – Jumping & Landing)
- Reactivity (Elastic Plyometric Programming & Agility Foundations)
- Fitness (Repeatable Bouts of Intense Work)
The program is designed to address these factors from both a rehabilitative, and a risk reduction stand point, making it an ideal program for Physical Therapists, Coaches and Practitioners in the sport and fitness realm. From a reduction of risk standpoint, a recent study points out another key aspect in regards to retention that mirror what we have seen over the last 12 years. Results suggest that training duration may be an important factor to consider when designing injury prevention programs that facilitate long-term changes in movement control (Padua, 2011). Training duration is referring to the athletes dedication to an ongoing program… There are no “quick fixes,” instead we are looking for a lasting result.
In this study, one group participated in a “prevention” program for 3 months, while another group carried out the program as a warm up for 9 months. While the 3 month group improved throughout the study, only the 9 month group was able to retain these effects 3 months after they stopped using the warm ups. My point is simple… Programs designed to reduce the risk of injury should not be viewed as short-term preventive programs. Instead they should be carried out for much longer periods, integrated into on going training sessions, and progressed over time. This is the only way these programs work. And even though in this text we progress through a phase based time line, these exercises, drills and movement patterns take time to develop and should be thought of as an essential part of year round athletic development programs.
The program is broken up into several phases that parallel the suggested introduction of new exercises and intensities based on 20 different ACL rehabilitation protocols we have received from physicians. These phases will generally run in 4 week blocks, but will require the patient / client to reach some level of aptitude before moving on to the next phase. It will also be assumed that the patient / client has no pain or medical limitation that would effect their ability to perform each exercise or activity within a particular phase of the program. These limitations could include, but not be limited to meniscus repairs, swelling, range of motion, infections, other injuries (ankle, hip, back), etc.
Phases of the Return to Confidence Protocol:
Phase 1: Weeks 1 thru 4 – Done at PT location only
- Return to weight bearing activity
- Reduction of swelling
- Improve quad control, ankle strengthening
Phase 2: Weeks 4 thru 8
- Introduce conditioning protocol on the Cybex Arc Trainer
- Closed chain strengthening activities
- Athletic balance and positioning drills (lunge progression video shown below)
- Strength training for non-involved side, core and upper body
Phase 3: Weeks 9-12
- Begin lateral movement work (controlled pace) – walking agility program
- Progress intensity on Cybex Arc Trainer interval program – A1 Mode (Controlled Watts)
- Progress intensity on strength training – Increase Load / Dynamic Movement / Circuits / Complexes
- Begin Plyo “Preparatory” Program (Jump/Landing and Box Step Up)
- 5 minute Block Circuits (alternate Cybex Arc with DB total body strength activity)
Phase 4: Weeks 13 thru 18
- Strength/power endurance – Progress 5 minute Block Circuits (PowerFIT Program)
- Low level plyos with a focus on elasticity (reducing GCT)
- Leg Press Drop Sets / Jump Squats or Cybex Arc Sprints Combination
- Intensify resisted cardio on Cybex Arc Progression of speed/agility, speed drills (form and confidence)
Although this program is set up in 4 week blocks, we sometimes have to hold an athlete back for a few weeks until they master the form, show adequate strength or demonstrate confidence in each exercise in that block. This is a general progression that focuses on the entire body. Instead of spending 12-16 weeks in a rehabilitative program which only focuses on the involved limb, we take the approach of conditioning and strengthening the entire body so that when the athlete returns to activity, they are stronger (and possibly fitter) than they were prior to the injury.
In our final post tomorrow, we will highlight several case studies of players who participated in our Return to Confidence Program. Here is a sneak peak at one of the soccer players Game Speed Profile.