Student blog: ACL rehabilitation in elite football
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Introduction
Anterior cruciate ligament injuries rank among the most prevalent and devastating injuries, affecting both amateur and elite athletes (van Melick, 2016). Despite the advancements in research and clinical practice, players playing at a professional level have a recurrence rate of 17.8% (Wright et al., 2007). Despite notable strides in research and clinical practices, professional players face a concerning recurrence rate of 17.8% (Wright et al., 2007).
Moreover, rerupture rates post-reconstruction range from 3-22% on the reconstructed ligament and 3-24% on the contralateral side, further complicating the rehabilitation process. The risk of a subsequent second ACL tear is not the only barrier to a successful return to sport, the return to preinjury level participation post ACL surgery is reported to be as low as 65%, underlining the multifaceted challenges athletes encounter in their journey back to peak performance (Ardern et al., 2015).
Against this backdrop, this blog endeavours to explore strategies for optimising ACL rehabilitation within the context of a multidisciplinary team (MDT) working within an elite football team setting. By delving into the workings of the MDT, we aim to elucidate how proactive organisational structures, effective rehabilitation planning, and open communication channels can bolster the success of rehabilitation efforts. Through these avenues, we seek to empower medical teams to navigate the complexities of ACL rehabilitation ultimately fostering the return-to-performance of the athletes with confidence and resilience.
Image 1. Multidisciplinary Team
The Medical Department
The medical department consists of a sports medicine physician (club doctor) and typically 2-3 physiotherapists.
The Sports Medicine Physician
The sports medicine physician is typically the case manager and will oversee the rehabilitation period (Villa et al., 2019).
The Physiotherapist
The physiotherapists in the MDT will be responsible for the majority of the ACL rehabilitation. The regaining of range of motion, strength, power, hypertrophy, balance, and coordination are well-established and researched goals for the athlete to achieve under the guidance of the MDT; specifically the physiotherapist (Taberner et al., 2020).
The Performance Department
The performance department has a vital role to play in the reconditioning of the athlete back to the pre-injury level.
The strength and conditioning coach(s)
Here, the strength and conditioning coaches will reintroduce upper-body training and more dynamic and full-body movements once the initial protective phase has been completed (add more detail) at approximately 2-3 months post-surgery. The reconditioning of the body is crucial to regain the physical profile to compete at the highest level but also to build resilience to mitigate any further injuries (Bizzini et al., 2012).
The sports psychologist
However, the reconditioning of the mind is equally important and can be less straightforward (Ardern, 2015). Often overlooked, the psychological aspect of an ACL injury in an elite footballer cannot be underestimated. Mental training techniques to manage pain and reduce anxiety associated with injury are essential (Clement &Arvinen-Barrow, 2013). The sport psychologist provides screening and support for the player, with early identification of psychological barriers being crucial. Specific questionnaires to assess athletes’ fear, confidence, and perceptions of risk can help tailor interventions to their needs. This proactive approach can prevent psychological issues from hindering physical recovery (Ardern et al., 2013). Setting specific, measurable, achievable, relevant, and time-bound (SMART) goals helps athletes build confidence and stay motivated during their recovery (Ardern et al., 2022). The psychologist also encourages autonomy and control by advising the player to take an active role in their rehabilitation alongside the medical staff. Positive mental imagery, such as visualisation techniques, helps athletes imagine a successful return to the football pitch, reducing anxiety and fostering a positive mindset toward recovery and performance (Ardern et al., 2013). ACL rehabilitation is not a straightforward process, and setbacks are inevitable. The sport psychologist helps athletes develop coping strategies, emphasising relaxation exercises, cognitive-behavioural strategies, and ensuring adequate social support (Ardern et al., 2022).
Furthermore, it is my opinion that both the medical department and performance department may help with easing uncertainty, doubt, and fear of re-injury from the start. The medical and performance staff’s plan should give the players objective and measurable targets to hit. Players are natural competitors, and a long-term ACL injury rips away a big part of their life that motivates them daily. Measurable and objective short-term goals and targets can help feed that competitive urge and motivate the player. In addition to this, speaking with another player who has gone through the same long-term injury can allow the sharing of experiences, challenges, and solutions that we as non-playing staff members can not relate to.
Image 2. Graded Exposure RTP Plan
Communication
Acute stage
Acute injuries such as an ACL tear challenge the resilience and organisation of the MDT and emphasise the importance of teamwork and communication in such situations. On match days, at least one team doctor and at least one senior physiotherapist will make up the medical team on the sideline (The Football Association, 2023). In the event of an ACL tear, the medical team needs to be well-equipped to handle this scenario by coordinating their efforts effectively and following a clear and pre-planned protocol. Below I have illustrated the process of coordinating an ACL tear in training or on a match day.
Acute Injury protocol:
Image 3. Acute ACL Injury Protocol