There was interest in learning “what” we do for each athlete within the ACL recovery program, but what we need to clarify first is the “why” these types of programs are needed. So these programs that I am referring to are what we classify as reconditioning programs, which are different from rehabilitation programs. For the sake of keeping the posts from getting too overwhelming, the content will be broken into three separate posts over the week. In this post I will discuss the fundamental difference between rehab and reconditioning, addressing the mindset shift needed to train around an injury, and the concept of the Load Compromised Athlete. This information could not be provided without the teachings of Bill Knowles, Director of Recondition and Athletic Development with the Philadelphia Union Soccer Academy. Bill is the worldwide leader in the reconditioning of athletes and has brought many of these concepts to the forefront. It is through his lectures and writings that I am able to bring this information to you.
Rehabilitation is a medical or clinical model for treating individuals who may or may not be athletes. Often, a surgeon will design and/or direct this protocol. With operations, the focus of the protocol is on the surgery, wound healing and early stages of rehabilitation. They usually emphasize protecting the peripheral lesion ﬁrst, and then promote slow controlled motion and activities of daily living. This continues for many months with the aim on “doing no harm” to the repair: Eventually, basic athletic preparation is typically encouraged to begin once biological healing time of the graft has advanced.
Reconditioning is a performance-based model for training athletes following injury or surgery. It is directed by the performance team and is medically supported. The program begins with the end in mind, which is a Return to Competition (I’ll cover this concept in depth later this week).
Training Around the Injury
Reconditioning follows a functional path immediately post-injury and continues this progression until the athlete has returned to competition. We recognize that a serious injury should be looked upon as a neurophysiologic dysfunction, not just a common peripheral musculoskeletal injury. It is a peripheral injury, but with a central consequence. With this in mind we must train the brain through movements, not just muscles, during all stages of post-injury care. Most protocols that restrict active motion, like brace joints, assist motion via continuous passive motion (CPM) machines or prevent loading are affecting the normal patterning that an athlete needs in order to best prepare for higher quality training in the weeks and months to come. For joint injuries, the best brace is neuromuscular control and coordinated movement patterns. These can be developed early and often if the protocol encourages doing so.
One of the biggest neurophysiologic changes that we see is altered kinematics (motion) and kinetics (force production) of the foot on the same side as the injured knee. These must be addressed prior to athletes progressing to any type of return to running protocol. This is a term we absolutely despise and will cover at length in a future post later this week. So make sure you check out that rant/discussion J
Often, rehabilitation protocols are centered on what an athlete cannot do, as opposed to what an athlete can do. While this is often a consequence of protecting the repair/injury, these limitations can compromise the short- and long-term movement qualities of the athlete. Unfortunately, rest is often the chosen form of protection, yet the short- and long-term neuromuscular inhibition that accompanies this approach may actually put the repair at greater risk as the athlete progresses.
The reconditioning model also respects protecting the repair and maintaining joint homeostasis but encourages more athletic ways to train the individual. Because reconditioning is performance-based, we prepare the athlete - we don’t just treat the injury. This is done through coaching movements that occur in daily training for the athlete, albeit at the correct intensity and load. This strategy maintains and/or restores coordinated movement patterns that are essential for athletic success in the future. Whether the response is physiological, psychological or both, the outcomes are excellent. The traditional medical model of rehabilitation, which focuses more on the injury, underestimates the total body healing response that training familiar movements has on athletes.
The Load Compromised Athlete
When an athlete injures a joint surface, ligament, muscle or tendon it is, to some degree, forever compromised. With increased severity comes an increased challenge to keep the tissue healthy over an athlete's career. There is clear evidence that an anterior cruciate ligament (ACL) injury leads to early onset osteoarthritis (OA) 5-15 years after injury, ‘aging’ the knee roughly 30 years. These degenerative changes can often exact a toll later in an athlete’s career. For knee injuries, these changes are attributed in part to quadriceps weakness as a result of arthrogenic muscle inhibition (AMI). AMI is an ongoing neural inhibition that prevents the quadriceps from fully activating and is believed to result from pain, swelling, inﬂammation, joint laxity and structural damage. Altered afferent information from the damaged knee joint is believed to have both spinal and supraspinal pathways.2 This ‘central consequence’ may alter dynamic neuromuscular activation patterns that affect lower extremity kinematics and kinetics leading to a negative change in load distribution across the knee joint.
Given that signiﬁcant levels of AMI may still be present 18-33 months following knee joint injuries,2 the central tenet of an ASP is that an athlete’s reconditioning must continue well after they return to competition. The reality is, after long-term injuries, we must continue to implement strength, power and coordination training throughout the season, the year and their career. In addition, LCAs cannot take more than two weeks off from strength training or they risk the neuromuscular ‘switching off’ that can predispose them to re-injury.
There is no bigger takeaway from this post than this last paragraph. Parents and coaches are looking for answers as to what their kids should do to prevent these types of injuries. The greatest predictor of injury is a previous injury. Coaches/parents specifically need to recognize this as the facts are backed in scientific evidence and the statistics aren’t going to correct themselves. The answer is found in the performance team that is medically supported. No part of that team is more/less important than the other, and they are all professionals. You don’t just pick any doctor; you go to the best doctor in the area. You don’t search for rehab protocols on YouTube, so why should the strength & conditioning/ reconditioning work be left to chance, or neglected entirely? We have the best interest of every athlete that walks through our doors. When we give a professional recommendation that an athlete must be involved in a year-round strength & conditioning program, it is because professionally it is the only acceptable answer based upon science and their general well-being. It has absolutely nothing to do with greed or the financial bottom line of our business. Hopefully the scientific data presented earlier makes that abundantly clear.
1 Palmieri-Smith, R.M., and Thomas, A.C. (2009). A neuromuscular mechanism of posttraumatic osteoarthritis associated with ACL injury. Exercise and Sport Science Review, 37(3), 147-53.
2 Rice, D.A., and McNair, P.J. (2010). Quadriceps arthrogenic muscle inhibition: Neural mechanisms and treatment perspectives. Seminars in Arthritis and Rheumatism, 40(3), 250-266.
3 Fyfe, J.J., Opar, D., Williams, M.J., and Shield, A.J. (2013) The role of neuromuscular inhibition in hamstring strain injury recurrence. Journal of Electromyography and Kinesiology, 23(3), 523-30.