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Rehabilitation of Female ACL Injuries

Rehabilitation of Female ACL Injuries

Soccer Specific Considerations

Marc R. Bernier, PT CSCS, HealthSouth Soccer International Director

Much has been publicized over the past several years regarding the incidence of anterior cruciate ligament (ACL) injuries in the female athletic population, in both the general media and sports medicine journals. Research studies consistently show that female athletes are between 4-8 times more likely to suffer a rupture of the ACL, with the sports of soccer, basketball and volleyball exhibiting the most pronounced injury rates. Many causative factors have been proposed as potential contributors to the increased ACL injury rates in females, and many of these same factors present clinical challenges in the post-operative care of female soccer athletes. Although there are numerous potential causes of ACL injury, the focus of this article will be on methods to address the neuromuscular deficits present in the female soccer player in the post-operative care, based on the soccer specific demands the player will face when returning to the field of play.

The overall goal during the post-operative rehabilitative process is restoring dynamic stability to the knee while protecting the surgically restored static stability. Unfortunately, probably one of the greatest contributing factors in female ACL injuries is the inability to provide appropriate dynamic stability during high intensity athletic activities. As a result, static stability is compromised leading to excessive stress being placed on the ACL. The challenge facing the clinician is how to improve the neuromuscular components of dynamic stability in female athletes so they can return to competition, when it is these same components that were deficient when the athlete was “normal” and “healthy.” Put another way, if the female athlete had poor dynamic stability before the injury, those deficits will be exponentially more pronounced during the post-operative treatment.

The physical demands of soccer also present some challenging considerations when rehabilitating these athletes. Skill performance in the sport results in tremendous forces being transmitted through the tibiofemoral and patellofemoral joints of the knee. The sport of soccer requires the performance of such skills as kicking, passing, shooting, trapping, cutting, and the ability to perform unpredictable and spontaneous footwork patterns during dribbling or avoiding tackles. The majority of these skills are performed while balancing on a single leg, which necessitates the ability to maintain appropriate dynamic stability and eccentric control of the knee while in a single leg stance position. This is one distinction of soccer that must be considered when implementing a treatment program; unlike most other sports, single leg support is more the norm than not during skill performance. As a result, the major component of the rehabilitation program must be on reestablishing neuromuscular control, including the kinesthetic awareness and proprioceptive pathways to ensure a safe and complete return to play.

The post-operative treatment program that has been utilized for soccer athletes of all levels (youth amateurs through European professionals) by this author emphasizes 4 main treatment philosophies, which consist of:

  • Proximal (hip/pelvis/trunk) and distal (foot/ankle) stabilization to control/promote proper lower extremity position and alignment.
  • Retrain stabilization patterns to emphasize hamstring activation as ACL protagonist.
  • Use of perturbation and footwork training for restoration of reflexive stabilization patterns and proprioceptive mechanisms.
  • Implementation of jump retraining and sport specific skill performance to correct improper mechanics and techniques.

Included in this treatment program are all typical components of strengthening, endurance training, balance, proprioception, etc.

Proximal and Distal Stabilization

One observation of female athletes is an inability to provide appropriate levels of stabilization both proximally and distally to the knee. Typically these deficits are more pronounced during clinical exam at the hip and pelvis. In non-operative female patients, these deficits can be observed in two manners: 1. Manual muscle testing of hip abductors and rotators; 2. Observance of valgus posture at the knee (increased dynamic Q-angle) during single leg stance and single leg squat maneuvers. The sport of soccer increases the importance of distal stability at the foot and ankle due to the slightly plantarflexed position the ankle assumes during skill performance, which must be dynamically controlled. This can also be observed during the single leg balance and squat tests by having the patient assume a slightly plantarflexed position while performing the maneuvers. Proximal strengthening is initiated in the form of straight leg raises into abduction and “clamshell” exercises, which can be implemented whenever ROM allows. The “clamshell” exercises are particularly preferred because of the simultaneous activation of the hip abductors and external rotators. Seated T-band rotations can also be used for strengthening of the internal rotators of the hip.

Single leg balancing activities are gradually progressed as the patient exhibits improved dynamic stability of the knee. The process typically begins with simulated volleying maneuvers while maintaining proper lower extremity alignment (Figure ….). Distal stabilization is incorporated by having the patient assume a plantarflexed position of the ankle while performing the same activities. As the treatment program progresses, the volleying motion assumes a more abducted position, which mimics the side volley in soccer (Figure ….). This skill requires a significantly increased level of dynamic control of the valgus posture the knee wants to assume during this skill. “Circle dribbling” is utilized, in which the patient stands on the involved leg and dribbles or taps the ball with the uninvolved leg in a semi-circle manner on the uninvolved side (Figure ….) Other activities include the use of surgical tubing for resistance during upper and lower extremity movement while balancing on the involved leg, also with the ankle in a plantarflexed position. All of the above exercise emphasize the ability to dynamically stabilize the proximal and distal joints to the knee, and have the added benefit of retraining the proprioceptive system and restoring kinesthetic awareness of the knee.

Dynamic Stabilization via Hamstring Activation

Studies have shown that females have a tendency to be “quad dominant” when it comes to attempting to stabilize the knee during functional activities. This concept is apparent in the manner that females tend to maintain a less flexed knee position when landing from a jump or attempting a cutting maneuver. This propensity to assume a more extended position results in a significantly higher quad activation compared to the hamstrings, which can result in an anterior shear force being placed on the tibiofemoral joint. Additionally, the less flexed knee position places the hamstring at a mechanical disadvantage by reducing its lever arm, which further reduces its effectiveness in acting as a restraint to anterior shear forces. This component is integrated into the treatment program by the performance of lunge walking and squatting on various surface. Lunge walking is performed while the athlete assumes what Wilk, et al termed the “position of stability,” which is 25° to 30° of knee flexion. Lunge walking is performed in multiple planes, beginning with straight ahead, and progressing to lateral, backwards, and forward zig-zags (Figure ….). The program is progressed by performing lunges on unstable surfaces, and through the use of external resistance such as sportscords.

Perturbation and Footwork Training

Wilk, et al was the first to describe the use of perturbation training in the treatment of female ACL injuries. This form of training focuses on the active stabilization of a joint against an imposed postural disturbance. This “perturbation” elicits a protective motor response, which results in the musculature around the knee dynamically stabilizing the joint. Fitzgerald et al theorized that this form of training would also reduce the episodes of instability in ACL deficient athletes during high level sporting activities, and also suggested that utilizing perturbation techniques during skill performance may facilitate more functional neuromuscular control responses with significant carryover to athletic competition. In addition to the exercises previously described by Wilk, soccer specific skills are incorporated into the treatment protocol, mainly in the form of volleying and trapping a ball while landing on an unstable surface (Figure ….). During these exercises, the perturbation is applied during the landing phase, in which the surface applies a postural disturbance that must be dynamically stabilized. Footwork or agility training is also incorporated into the clinical treatment of the female, via the use of agility ladders. Improper footwork or poor footwork can be disastrous in the sport of soccer, by forcing the player to assume deleterious positions in an attempt to regain possession of the ball or lunge after an opponent. After ACL reconstruction, regaining quick footwork and restoring agility are imperative to avoid future potential injury. The ladders are placed on the floor, and the patient is required to perform series of varying patterns while jogging along the ladder (Figure …). These exercises are excellent tools for retraining the reflexive stabilization patterns in an environment of increased speed, which in turn retrains the hamstrings to activate more quickly during functional activities. Additionally, use of these devices can also allow the clinician to evaluate the patient’s ability to dynamically stabilize the knee during more functional activities, and address any deficits that may need to be worked upon. Agility training in the clinical setting will establish a firm neuromuscular foundation from which the player can begin the resumption of soccer specific training on the field.

Jump Retraining

Jump retraining is one component that is commonly overlooked in the post-operative care of female athletes. Hewett et al described a formal jump retraining program that focused on reducing the forces imparted to the knee during the landing phase. Results of their work revealed that it was possible to alter the mechanics of landing so that less stress is placed on the knee. Additionally, an reduction in the number of ACL injuries was achieved in participants in the jump retraining program, as was an increase in vertical jump height and an improvement in the hamstring/quadriceps ratio. Jump retraining may have an even greater importance during the post-operative treatment protocol. Many ACL injuries in females have resulted from poor landing techniques during athletic activity. It is very important to realize that these poor techniques will be even worse after ACL reconstruction, and in many instances, athletes are allowed to begin plyometrics using box jumps without retraining the techniques of proper landing. It would be a big disservice to the female athlete to fail to address these deficits post-operatively; if ignored, the athlete will be at a higher risk for re-injury upon returning to play. This author uses a modified version of the program described by Hewett et al. Emphasis is placed on the basic components of proper landing and jumping techniques, with the addition of soccer specific skill performance included in the latter stages. Due to insurance limitations in today’s healthcare environment, most of this program must be completed by the patient outside the clinical setting, with evaluation of technique and progression occurring during the patient’s treatment in the clinic. In many instances, the patient is instructed to perform the outlined exercises while attending soccer practice, since participation in the sport is not allowed at this time, and the athlete is usually eager to do something while standing on the sideline. Perfect technique must be demonstrated in the clinic before progression to more advanced jumps is allowed. The goal of this article was to discuss some key components of post-operative ACL rehabilitative care for female soccer athletes, in a manner that was functional for the sport of soccer and optimally prepares the player for a return to soccer training. The treatment philosophies discussed here have also been integrated into the treatment of many male professional European soccer players, and has been extremely effective in expediting their return to the elite level of performance. One player received post-operative care for a reconstructed ACL and MCL, and another player suffered ACL injuries to both ACL’s 1 year apart. Both players were able to return to the highest level of competition, and played in last year’s World Cup Finals, finishing 3rd overall.

Marc Bernier is a senior physical therapist and strength and conditioning specialist at the HEALTHSOUTH Sports Medicine at Rehabilitation Center in Birmingham, AL. He is also the Director of HEALTHSOUTH Soccer International, Sports Medicine Consultant for the Galatasaray Football (Soccer) Club (2000 UEFA Cup Champions) and is the Director of Sports Medicine and Performance Enhancement for the Mountain Brook Soccer Club in Birmingham, AL. He can be contacted for questions or comments at 205-930-4700 or e-mail at marc.bernier@healthsouth.com.