Part 2: Return to Sport after ACL Injury: What Should be Assessed?

You’ve been cleared from physical therapy but are not quite ready to return to your sport yet. What is the next step? Depending on your injury, there are two routes you could take. ACL injury? Enter: The ACL Performance Lab at Made 2 Move. Any other injury?  Enter: Made 2 Move Performance Therapy, one of our favorite things at Made 2 Move. Returning to sport following an acute injury can be scary, so performance therapy helps fill this gap between PT and fully returning to your sport. 

Who better to ask about the components of RTS rehab than Laura Sapper, ATC, OTC, CSMS? Laura is one of our ACL rehab and sports performance specialists at Made 2 Move. When asked what the most important aspect of a RTS program is, Laura states, “Making sure you are recreating the environment of the sport you are trying to return to. Is that single leg landing being done under fatigue? Is that deceleration and change of direction drill against a defender? Is it contact? If rehab doesn’t look like the sport you’re trying to return to, then you won’t be prepared.”

Last week’s blog delved into hop testing not being the “end all, be all” in a return to sport (RTS) protocol. So what should a RTS protocol entail? This blog is not all emcompassing, as RTS is highly comprehensive and individualized, but we are going to go through the gist of what a RTS protocol should entail following ACL injury or surgery. 

What Should be Included in Return to Sport (RTS) Rehab? 

#1- Apply concepts of progressive overload.

Progressive overload is the concept that exercises have to be advanced (made harder) in order to elicit adaptations. Essentially, it is challenging the body beyond the capabilities in the weeks and months prior so that you can get faster, stronger, and more athletic. This can be done by varying the load, reps, time, or complexity of the exercise. 

A recent article noted on rehab and functionality following ACL reconstruction, “Primary principles to be discussed include progressive overload, specificity, and variation…these variables are manipulated so that the dose is sufficient to elicit adaptation but within an individual’s recovery capacity” (Larson et. al 2021). This is the KEY. Progressive overload must be balanced with recovery: proper sleep, nutrition, and rest days. 

Some of the areas in which our Made 2 Move clinicians will progressively overload players include: 

• Isolated muscle strength

• Deceleration

• Landing mechanics

• Power production

• Plyometrics

• Endurance

• Movement competency and coordination

As you can see, the RTS protocol utilized here is all encompassing, hitting on vital components of athleticism required to get you back on the court, rink, gym, or field. 

#2- Mimic your sport through functional movement individualized to you.

Darren J. Paul, a physiologist and PhD candidate summed it up perfectly, “There currently seems a bias toward assessment and monitoring of variables which are easy to measure, rather than what is important. For example, screening methods that include visual assessment of control of the knee during a slow, single leg squat or hop are likely very different to movement variability during an unplanned direction change task while fatigued and under high cognitive loads” (Paul 2023).

Slow controlled movement and visualization of exercises are great in the beginning and middle phases of rehab when athletes are relearning movement patterns and building strength. However, in the final stages of rehab, your exercises should look very similar to your sport. If you’re a basketball player trying to return to the court, horizontal hopping should not be your final step before stepping on the court again. These hops can give us clues into your progress along the way, but we must progress to game like scenarios to make sure you are moving fluidly and fearlessly through that lay-up! 

Some of the sport specific tests you may go through at the Made 2 Move ACL Performance Lab include: 

• Isometric quad, hamstring, and calf strength testing

• Pogos

• Squats and jump squats

• Y-balance drill

• 3- step deceleration

• Single leg vertical hop

• 300 yard shuttle

• 5:0:5 test

• Max sprint on treadmill

If you are a soccer player, our therapists may even have you bring a ball in! We want to see how you pass, dribble, cut, etc. before we clear you to hit the field again. 

It’s great to build strength in PT, but if you can’t apply this strength to your sport, then what’s the point? Sports require so much more than just brute strength. If you can do a lateral lunge with a barbell, this is GREAT, but if you can't control this at high speeds then you may have fallen short in the deceleration and motor control piece of rehab, putting you at risk of another ACL injury. You need stability and body awareness through the trunk to hold off opponents or to come down safely from a header or layup. You need agility and change of direction (COD) abilities in order to juke out that defender. You need perturbation and motor control training to gain a greater sense of where your body is in space. You need confidence in your movement patterns and capabilities, which hits on the last major component of the RTS puzzle: the cognitive piece. 

#3- Continually perform cognitive assessments. 

In recent years, the concept of “psyhcological readiness” in returning athletes to their sport after an ACL injury has gained momentum, and rightfully so. 

An 2016 article by orthopedic surgeon Dr. Reaume touched on 3 of the psychological considerations that must be evaluated in an athlete after ACL injury (Reaume 2016). These 3 considerations include: 

1. Kinesiophobia

   1. Kinesiophobia refers to a fear of movement. This is common after injury and often stems from a lack of confidence in the knee or fear or reinjury. That is what we are here for at Made 2 Move: to help you believe in your knee! 

2. Self-efficacy

   1. The concept of self-efficacy has been around for many years and is simply, “an individual's belief in his or her capacity to execute behaviors necessary to produce specific performance attainments (Bandura, 1977, 1986, 1997). If an athlete doesn’t believe in their ability to heal and get back to sport, it will not only influence their actual recovery in PT, but it will also influence their motivation and desire to even show up to PT. This is why we consistently check in with our athletes to see where their head is throughout the rehab process. 

3. Control

   1. Dr. Resumes refers to this as an athlete’s “locus of control” and states, “locus of control refers to the degree to which an individual believes they have control of the outcomes of their lives as opposed to control being dictated by external forces” (Reaume 2016). This is relevant to any aspect of life but becomes especially important during the RTS process. It is imperative that an athlete feels like they have some control over the rehab process and outcome of their injury, which is why we rely heavily on an athlete’s input and feedback throughout the rehab process at Made 2 Move. It is your body- we are just here to help!

Performance Training at Made 2 Move

There are many vital aspects of a return to sport protocol and it is crucial that your rehab plan is all-encompassing. This blog focused primarily on RTS protocols for ACL injuries, but the same principles can be applied to any injury with the tweak of a few tests. Interested in working with Made 2 Move on your return to sport comeback? Email frontdesk@made2move.com today to set up an initial evaluation!