Anterior Cruciate Ligament Reconstruction Return To Sport: On-field Rehab

 

 

 

Background

Prior to this project presenting itself as a possibility, I have always been passionate about evidence based practice in the realms of sports medicine, sports physical therapy, athletic training, and human performance enhancement. Before starting in the DPT program here at UNC, I graduated with my degree in athletic training from Emory & Henry College which allowed me to work in multiple athletic venues across a variety of sports through my clinical affiliations. I have also been very fortunate to work in different roles as a licensed athletic trainer in the state of North Carolina while also studying to become a physical therapist. These experiences have allowed me to form a strong interest in rehabbing athletes with a wide array of impairments and injuries (patellar tendinopathy, lateral ankle sprains, SLAP lesions, patellofemoral pain syndrome), but I am particularly interested in the anterior cruciate ligament reconstruction (ACLR) rehabilitation process. This is a topic I have continued to explore the literature on, discuss with classmates and clinicians, attended continuing education courses for, and even discussed in various journal club meetings.

My partner, Ryan Brooks, and I first heard of this project in October of 2020 from Dr. Louise Thoma who brought the project forward as a potential capstone opportunity. Ryan and I immediately jumped at the chance to participate in the project and to put our brains together to create very useful and ready-to-implement evidence based materials for the practicing clinician. Ryan’s side of the project focused on return to sport testing and in clinic rehab (see Ryan’s project here), while my side of the project involved the on-field rehab process. This portion of the project pushed me to dive into an area I was less familiar with and has helped me grow my base of knowledge exponentially. I feel I have a strong foundational knowledge in the areas of resistance training in rehab, current best practices for testing in the rehab process, and in exercise prescription, but the on-field rehab area was one that I had not previously taken a deep dive into.

 

Statement of Need

Despite some common views of anterior cruciate ligament reconstruction (ACLR) rehabilitation within the profession, there is a clear and significant gap faced by athletes who incur this injury and attempt to return to high-level sporting activities. While outcomes vary and the exact number of secondary ACL rupture following ACLR is not known, it has been reported that reinjury occurs in 6% to 31% of cases where injuries can be seen to either the postoperative or contralateral knee.^1,2 There are many proposed theories and correlations related to why retear rates and/or contralateral knee injuries may be this high ranging from poor testing procedures in the rehab process, lack of recovery of force production qualities in the quadriceps muscle group, altered knee kinematics in functional or sport-specific tasks, lack of use of criterion-based rehab protocols, and athletes returning to sport too soon after injury. Within this process and timeline falls a difficult portion of rehab, that can greatly aid athletes in a successful return to sport program, known as on-field rehabilitation.

On-field rehab refers to the “period between gym based rehab and competitive team environment” and currently represents an area with a paucity of evidence in how to properly conduct it.³ This period of time represents a crucial point for rehabilitation professionals working with athletes post ACLR as injuries to the graft have been noted to occur early into the return to play (competitive) period (injuries can occur shortly after return to full match play and within the first few months of return to competition).^4,5 These numbers represent the period after rehabilitation has been completed and mark the importance of using a proper transitional period from gym based rehab to full speed competition. The current lack of evidence in how the rehab professional should approach the on-field rehabilitation period presents a clear issue, but this capstone project seeks to explore the literature that does exist and create a guide for clinicians that is practical and can be readily implemented in the outpatient setting to ensure the athlete has been exposed to the movements, speeds, durations, energy systems demands, and sport-specific skills needed to succeed in their respective sport. In real world clinics (such as the typical outpatient orthopedic setting), there are certain constraints which this capstone will seek to discuss and address such as clinic space, equipment, rehab duration, and increasing knowledge of performance enhancement and reinjury risk reduction throughout the process. While covering the specifics of many different sports would be outside the scope of this capstone, what will be provided to the clinician is a set of guidelines with specific goals that need to be achieved during the phases of on-field rehab to guide the clinician with their decision making based on the athlete they are working with.

 

Purpose

The overall goal of our project was to create a set of materials focusing on ACLR testing criteria and on-field rehab that could be readily implemented by the practicing clinician. For more information on the criteria based testing see Ryan’s side of the project here. The goal for the on-field rehab portion evolved as we continued having discussions amongst the project members and the committee, eventually forming into the goal of creating one page summary sheets involving the stages of on-field rehab, entry criteria for each stage, goals of the stages, and example activities as well. Additionally, we created a database of videos which are around one minute each in length and give a snapshot of drills, tasks, and exercises that can be immediately used by clinicians. We also set out with the goal to create a one page summary for patients that parallels that of the clinician, with simpler language, so that they can be on the same page with each step of the process. To address health literacy and create engaging educational materials, we also wanted to create infographics for both the clinician and the patient. Through these materials, we were able to explain and expand upon the transitional period known as on-field rehab as it is a nuanced topic with emerging information related to its importance in the return to sport process.

 

Products

Products created include the following:

• One page summary handouts (clinician, patient, simple deceleration progression)
• Capstone Google Form outline for clinicians
• Narrative review for clinicians
• Short health literacy explanation
• Video presentation for clinicians
• Presentation slide deck
• Clinician infographic
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• Patient infographic
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Evaluation

Evaluation was, is, and continues to be a fluid process with multiple sources of information. One of the first evaluation methods used were frequent meetings with my partner Ryan Brooks (weekly and up to three times per week) to discuss both sides of the project. Ryan is a great source of information, especially with his background in strength and conditioning, and these meetings allowed us opportunities to bounce ideas back and forth and brainstorm our topics. During these meetings, we also created the infographics for our project which allowed us a base of information to begin asynchronous work before coming together a final time to touch up the infographics. Along with these meetings, we had periodic meetings with our committee to discuss the status of materials, changes to our plans, new ideas, and to receive feedback on the direction in which the project was heading. At the midterm, we submitted materials for feedback from the committee and began to create and/or refine the products which are presented on this website. This allowed us to identify gaps in the presentation of the materials and to create concise products. Finally, our materials were shared with physical therapists within the UNC outpatient setting and physicians associated with ACLR patients at UNC along with a Google Form questionnaire for feedback (as of April 7^th). We consider these individuals “stakeholders” in the project and are currently in the process of receiving and compiling responses related to the materials in order to see what changes may or may not be necessary to ensure the usability of the materials. Once enough responses have been recorded, specific changes can be made which will then make the final resources appropriate for implementation.

 

Self-assessment 

As I stated previously, this project gave me a greater understanding of the world of on-field rehab following ACLR related to possible stages to use, progressions to follow, theoretical concepts to implement, and the current body of evidence on the topic. My ultimate goal is to work in the sports medicine/rehab setting with athletes participating in sports with high risk demands and activities that may lead to athletes incurring ACL injuries. This project has allowed me to boost my confidence in the transitional period between traditional gym-based rehab and returning athletes to competition and I feel will serve me well in the future. I look forward to compiling the data we receive from the feedback forms to make some final edits to the materials and ultimately to see them used in practice in the outpatient setting here at UNC. I also look forward to (potentially) presenting these materials as part of an inservice style presentation during my final rotation in outpatient orthopedics here at UNC.

 

Acknowledgement

First, I cannot thank all of the following individuals enough for their support throughout the process. It has truly been a pleasure working with you all.

To Ryan Brooks, thank you for taking on yet another project with me and for always being a great partner. We have teamed up since the very first day of PT school and I am proud that this is the project that we get to go out on. We have always kept each other motivated in staying up to date with sports medicine literature and practices. I always look forward to our conversations related to the profession and to hearing your insights when I have questions. You have been a wealth of knowledge for me, a great lab partner, a great project partner, and most importantly a great friend. You have an incredibly bright career ahead of you and I am excited to follow it.

To Dr. Louise Thoma, thank you for being our capstone advisor and for bringing this project to our attention. Ryan and I were planning to work on a project together regardless of the topic chosen and the fact that we had the opportunity to work on a project such as this was incredible. We both learned so much in talking to you, both related to the project and for moving our careers forward in the coming years. Your feedback was always helpful in moving the project forward and keeping us on track with our goals. Thank you for everything and I look forward to staying in touch in the future!

To Dr. Madison Franek and Dr. Michael Lewek, thank you both for being our committee members and for allowing us to reach out with questions and for guidance through this process. Our email and Zoom discussions aided so much in creating the foundation for the project as well as to keep the project in a concise and realistically usable fashion. Madison, your expertise in the areas of strength and conditioning and on-field rehab helped me to find resources and understand how to translate them to practice in an effective manner. I always enjoyed reading the additional articles you were able to share to advance the project along.

 

References for this page (see resources for other reference materials).

1. Wright RW, Magnussen RA, Dunn WR, Spindler KP. Ipsilateral Graft and Contralateral ACL Rupture at Five Years or More Following ACL Reconstruction. J Bone Joint Surg Am. 2011;93(12):1159-1165. doi:10.2106/JBJS.J.00898
2. Paterno MV. Incidence and Predictors of Second Anterior Cruciate Ligament Injury After Primary Reconstruction and Return to Sport. J Athl Train. 2015;50(10):1097-1099. doi:10.4085/1062-6050-50.10.07
3. Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field Rehabilitation Part 1: 4 Pillars of High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restoring Sport-Specific Skills, and Progressively Developing Chronic Training Load. J Orthop Sports Phys Ther. 2019;49(8):565-569. doi:10.2519/jospt.2019.8954
4. Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field Rehabilitation Part 2: A 5-Stage Program for the Soccer Player Focused on Linear Movements, Multidirectional Movements, Soccer-Specific Skills, Soccer-Specific Movements, and Modified Practice. J Orthop Sports Phys Ther. 2019;49(8):570-575. doi:10.2519/jospt.2019.8952
5. Waldén M, Hägglund M, Magnusson H, Ekstrand J. ACL injuries in men’s professional football: a 15-year prospective study on time trends and return-to-play rates reveals only 65% of players still play at the top level 3 years after ACL rupture. Br J Sports Med. 2016;50(12):744-750. doi:10.1136/bjsports-2015-095952