The last thing any player wants to hear is the diagnosis of an anterior cruciate ligament (ACL) tear. That’s usually because ACL injuries are associated with a lengthy period of rehabilitation once the operation is over; but also because the final stages of rehab can be the most challenging.
Coming to terms with the fact that they are going to be out injured for around six to nine months is bad enough on its own; but when you factor in how many players go on to sustain repeat ACL injuries it’s easy to see why there are doubts in players’ minds about whether they will recover to pre-injury status.
So although most players who have recently sustained an ACL injury will be focussing on the imminent surgery that lies ahead, the real challenge lies in a few months’ time when they’re back up and running. At that stage players are going to be thinking about their return to full training – and that can often be the most difficult period.
The key to managing ACL injuries often lies in understanding how the rotational movement of the knee relates to football and in particular, the position of the knee at the time the injury is sustained.
It is the rotational - or twisting - movements associated with football that often put the knee under the most stress. We frequently refer to a ‘twisted knee’ when describing injuries of this nature and this equates to how most forms of internal derangement occur.
Anatomically, the ACL is one of two strong ligamentous structures deep within the knee joint that connects the femur and tibia with the purpose of preventing excessive knee movement in a backward or forwards direction, the other being the posterior cruciate ligament (PCL).
In football though, the movements of the lower limb don’t fit into such specific categories. Think about the way players run, and you will see that the actions of the knee joint are not just confined to forward and backwards movements as described above; there are sideways movements as well which stress the collateral ligaments situated on either side of the joint.
When rotation is added and the movements of the knee are all combined, there’s a lot of stress placed on the joint itself. This stress is increased by the repetitive actions of football which involve twisting and turning, running and jumping etc.
Despite recent advances in the modern game, the components of fitness for football as defined by Coutts and Grant, (2005) and Bordon, (2006) of speed, strength, agility, power and flexibility still stand, all underpinned by a strong capacity for aerobic endurance.
So, in order to successfully return to fitness after ACL surgery, all these components have to be addressed progressively during the rehabilitation period.
Most players find that the main concern is that although they are able to address two or three of the above components at any one time during the rehabilitation period, there will be situations where they will be required to address most of these in one play - such as making a multi-directional sprint or taking a tackle on the turn at high speed.
Another risk is in jumping and landing at an awkward angle or having some slight but important muscle imbalances in and around the operated knee.
If you add coordination and balance to the mix and include proprioception (which is the sense of knowing where your limbs are without actually looking at them), then there’s a lot of fine-tuning to be done in the later stages before most players are actually safe enough to be able to return to the full squad.
In practical terms, muscles and ligaments all work in tandem with their opposites. The quadriceps muscles of the front of the thigh act with the hamstring muscles at the back of the thigh for example, and all are at their most effective when the balance between both groups is correct.
If the balance between both is disturbed and results in certain structures being put under more stress than its opposite, that’s where the risk of injury recurrence increases dramatically. This partially explains why players being rushed back from injury are at a disadvantage.
Although the injured ACL or meniscus may have recovered, the muscle balance may not be at the correct ratio; and when rehabilitating the knee joint getting this balance correct is essential. This is particularly important after something relatively major like an ACL injury.
Another risk following successful ACL surgery is again evident at the return to training stage; and that is in a player’s timing and sharpness.
Reactions, like everything else, have to be developed and you can usually spot the player who has been out of action for some time because they react that fraction of a second slower in uncontrolled situations on the field which again often leads to recurrence of injury.
This last aspect of returning to play is often the one that’s most evident. Even in the early stages of rehab immediately after surgery, most players will already be thinking about their return and counting the days, weeks and months until they are back in the team.
It’s only natural to do this but players won’t be fully recovered until that sharpness returns and that will be the main challenge to most club medical and fitness teams. Often the hardest part of returning to play is in regaining that essential reaction time and total match fitness.
The latter is difficult; and the problem affects everyone involved in the rehab process. For the rehabilitators, the issues lie in integrating both training for match fitness and working towards improving reaction times effectively enough to allow a player to return to full contact training.
Bordon C (2006). Training Methods. In Football Traumatology; Current Concepts from Prevention to Treatment. Volpi P (2006). Milan; Springer. Pp 23 – 31.
Coutts AJ, Grant A (2005). Training aerobic capacity for improved performance in team sports. Sports Coach Australia. Vol. 27 (4)y are.