While injury in sport can still be career-threatening, substantial progress has been made in the past 20 years to better rehabilitate common sport injuries and allow athletes to return to high performance sport. It wasn’t long ago that an anterior cruciate ligament (ACL) or ulnar collateral ligament (UCL) tear would mark the end of an athlete’s career, depending on the sport played. The sports world is filled with the “what if” stories of high-level athletes such as Gale Sayers and Bo Jackson who suffered career-ending injuries in the prime of their athletic careers. New surgical techniques and research on rehabilitation protocol have allowed for some athletes to come back stronger than ever from these kinds of injuries, but some athletes still fail to return to peak performance even from the same injury that others completely recover from. As an athlete who simultaneously rehabilitated from an ACL tear and a proximal patellar avulsion (where the top of the kneecap that attaches to the quadriceps muscles breaks completely from the rest of the kneecap and renders the quadriceps muscles useless), I am qualified to say that rehab is grueling, but it’s worth it if it is done properly. I was lucky; I was told I may never run again, but I worked hard alongside some great therapists and I am almost back to full strength one year later. It is imperative to understand the practices that best enable athletes to return from common injuries and perform at a high level again, whether you are going through the rehab yourself or are rehabbing someone else. Examining studies on recovery from ACL and UCL tears allows for some generalization on themes that allow for this successful return to maximal athletic performance.
One of the common themes among the recent studies on recovery from ligament tears is that a quicker return to exercising and loading the repaired ligament allows for both faster and more complete recovery. The research shows that immobilization is actually detrimental to postoperative recovery from both ACL and UCL reconstructions. It is even recommended that an athlete recovering from ACL reconstruction return to complete weight-bearing on the injured leg in a maximum of 10 days, and weight-bearing is generally prescribed to begin as soon as possible. Similarly, the research also suggests that quicker resistance training of the injured joint (particularly with eccentric exercises) allows for more successful rehabilitation than more cautious approaches do (Gokkler; Wilk). The focus on eccentric exercises (including plyometric exercise in as few as 8 weeks) (van Grinsven) in both rehabilitation and injury prevention is a relatively new area of study. As far as rehabilitation goes, eccentric loading of the repaired ligament results in more healing due to increased blood flow and collagen formation at the affected joint, thus allowing for faster and more effective healing of ligaments (Wilk). Eccentric exercises also allow for more direct strain on the ligament in question (ex. the ACL serves to prevent excessive anterior tibial translation, and eccentric quadriceps exercises may cause slight anterior tibial translation, putting some strain on the ACL), which will promote healing when it’s not overdone. This is not to say that concentric exercises are ineffective, but the research shows there is a definite advantage to an eccentric focus on exercise specifically to train and heal the repaired tissue. Eccentric exercises also allow for more force production in the joint, further supporting the theme that faster return to normal activity and more strenuous exercise supports overall recovery from injury. It is obviously important not to overtrain and reinjure the repaired tissue, but increasing workload and intensity of exercise while maintaining a safe environment for healing allows for a much better recovery than passive, overly-cautious approaches to rehabilitation. A fine line must be walked when programming recovery exercises for athletes.
It is also imperative to remember that complete rehabilitation must be part of a comprehensive exercise plan. Research shows that better recovery occurs when a comprehensive training program is followed and parts of the body other than the recently repaired area are trained (van Grinsven). This is for two reasons: increased circulation of blood aiding in the healing of the injured area and more efficient motor learning/neuromuscular control allowing for the exposure and treatment of abnormal kinematics in common activities. Again, it is important to recognize the limitations on training and avoid the risk of re-injuring the repaired tissue, but to also push hard to regain the same level of performance as before the injury (if for nothing else than to minimize the chance the tissue fails later in life). The important thing to consider is that the athlete is working toward returning to complex motions involving the entire body (including walking, running, lifting, and jumping), and training to perform these functions cannot be done effectively without incorporating the rest of the body to work together with the recently injured area. Core and stability training becomes crucial to maintain proper motor control, and can even be used as a cardiovascular training exercise to increase blood flow (which will aid in the healing of the affected area). Limiting training of other areas because of the injury is detrimental to overall recovery because of the decreased neuromuscular control of basic activities. Examples to consider specifically involving ACL and UCL tears would be Russian twists and strict overhead dumbbell presses for ACL rehab, and bodyweight squats and leg lifts for UCL rehab.
The overarching theme is that working harder is better as long as the load is kept light enough to avoid re-injury and the athlete is carefully supervised. Fitness professionals should be smart when training athletes in the months following surgery, but should not coddle the athlete or be too passive in their programming. There is no universally accepted protocol for rehabilitation for either ACL or UCL reconstruction (let alone specific to graft selection or simultaneous injuries such as the “terrible trio” of ACL, MCL, and medial meniscus tears), so careful consideration must be taken when programming to work the repaired area as hard as possible while maintaining a safe training environment (Abrams). Eccentric exercises specific to the injury and comprehensive training are the best approaches to heal the injury and maximize performance going forward.
References:
- Abrams Geoffrey D. MD et al. Functional Performance Testing After Anterior Cruciate Ligament Construction, A Systematic Review. 21 January 2014. Web. 6 February 2016.
- Gokeler Alli. Bisschop Marsha. Bejnaminse Anne. Myer Greg. Eppinga Peter. Otten Egbert. Quadricpes function following ACL reconstruction and rehabilitation: implications for optimization of current practices. 28 June 2013. Web. 6 February 2016.
- van Grinsven S. Cingel R. Holla C. Loon J. Evidence-based Rehabilitation Following Anterior Cruciate Ligament Reconstruction. 13 January 2010. Web. 6 February 2016.
- Wilk Kevin. Macrina Leonard. Cain Lyle. Dugas Jeffrey. Andrews James MD. Rehabilitation of the Overhead Athlete’s Elbow. 5 September 2012. Web. 6 February 2016.
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