Introduction

The Late Stage ACLR Rehab: The Field Based Athlete Masterclass, taught by Dr Brooke Patterson and Mick Hughes, provides a thorough overview of how to assess and prescribe exercises for an athlete who is returning to their field-based sport. This Executive Summary provides clinically relevant, actionable information that may be useful to health professionals.

Part 1: What does return to sport look like?

The end stage ACL resistance program for the field-based athlete should be goal focussed with an emphasis on quality over quantity, especially with the power-based drills. The resistance training program should be built upon a base of lower limb strength, acceleration/deceleration work, change of direction, single leg power (linear, mediolateral, and vertical), quadricep/hamstring exercises and optional core drills. Clinicians need to encourage athletes to continue their exercises post 12 months for general health and wellbeing and consider the athlete’s accessibility to gym equipment and whether they can self-progress.

• Isolate the quad through gradual increase in load with open chain knee extensions. The knee extension can be used to target either strength or power output, pending what the assessment findings are.
• During the back squat, you can bias their ACLR leg by lifting it slightly using a step or asking the athlete to stand in a split stance with their ACLR leg slightly back compared to the contralateral limb.
  

Part 2: The Field-Based ACLR Program

The end stage field-based program should include running drills/injury prevention warm up, high speed running/sprinting, acceleration/deceleration, multidirectional movement with changes of direction (COD), sport specific drills, training and appropriate distance running exposure. If the athlete’s strength markers are at 80-85% limb symmetry, it is suitable to introduce these field-based exercises as their confidence and strength will continue to improve with a gradual exposure to increasingly chaotic drills.

• When designing a running program, take into consideration the work:rest ratio of their sport. It is appropriate to expose the athlete to top speed running before introducing intense acceleration work. A good way to introduce high speed running and acceleration is the walk jog high speed jog walk drill.
• The graded exposure continuum for COD training is S-bends 45 degree 90 degree 135 degree 180 degree cuts. In addition, reactive COD with cones and a partner tag/tackle drills can be implemented. If the athlete is lacking in strength, power, or confidence, it will be exposed in the way they attack the COD drills which may indicate a re-assessment of certain outcome measures.
• Sport specific drills should commence with 1 v 0 (inanimate stress e.g cones) or 1 v coach 1v1 (another player) small sided games e.g 3 v 3 grid games. With each phase, the clinician can manipulate predictability, variability, and randomness to increase the stimulation for the athlete.
• Athletes can use smart watches to monitor their overall weekly training loads to reduce the risk of over training.
  

Part 3: Return to Sport Testing Considerations

When guiding the athlete through the end stage return to sport testing, there are an abundant number of tests that assess the athlete’s hop/jump ability, COD confidence, and agility. There are strength assessments using isokinetic machines and/or gym equipment which can be compared with normative data. Returning to performance is on the continuum of returning to sport, so the continual refinement of the athlete’s performance markers is essential.

• With the SL hop test, females and males should aim for at least 80% and 90% of their height, respectively as a bare minimum. Clinicians should be cautious when introducing the side hops as a drill, considering their capacity for the medial hop back. The athlete’s confidence will help dictate the volume of this test to include.
• Reactive strength index (RSI) is calculated by dividing the jump height (m) by the ground contact time (s) and can be measured from the counter movement drop and the 10-5 repeated jump tests. “My Jump” is a valid and reliable phone app for measuring RSI if the clinician does not have access to force plates. The surface and instruction given for this test should be kept consistent.
• The isokinetic testing machine can measure to peak torque (N) to bodyweight (kg) to which the normative data suggests for the quadricep muscle group that females and males aim to be between 2.3-2.7 and above 3.0, respectively. Alternatively, to measure strength, tests using handheld dynamometers include the isometric knee extension at 30 deg, isometric knee flexion at 30 deg, break test 30-0 deg and supine outer range eccentric may be used.
• Gym testing with exercises such as bilateral squat (>1.5 x BW), deadlift (>1 x BW), leg extension (>0.5-0.8 x BW + symmetry), single leg press (>0.8-1.5 x BW + symmetry), side bridge (>60s + symmetry) and Copenhagen adductor (aim >30s + symmetry) is another method of measuring strength and checking LSI.
• Change of direction tests include the 5-0-5 test which looks at the 180 deg turn, the agility T-test and Illinois agility test. Warren Young’s agility test is a 15m by 15m grid and has different starting positions that are standardised with both the attacker and defender having a go and then they are given a score out of 10 with how many touches they do.
  

Part 4: Psychological Factors and Assessment

There are multiple psychological, social, and contextual factors that may impact or reinforce the athlete’s physical rehabilitation. There are many conversation starters and assessments tools to assess the athlete’s psychological readiness and confidence at their individual stage of rehabilitation.

• As the clinician, be adaptable and offer variety when it comes to the rehabilitation program, with a strong focus on what the patient can do, rather than their impairments. This will foster a good therapeutic alliance with the athlete and help them be honest when it comes to how they are feeling mentally and physically for that session.
• Understand who and what the athlete has in place for support. Try to work with them to give tangible support so they can do their exercises with less barriers.
• Take into consideration the realistic frequency of sessions they can have with the clinician as well as any time pressures to return to a certain goal. Try encouraging self-progressions and online resources such as the Melbourne return to sport ACL guide, ACL focussed Physiotherapists on social media and TREK exercise prescription guidelines.
• Having conversations with the athlete often lead to transparency and trust and may expose barriers to progression. It also helps to connect the athlete with other people going through similar journeys as extra support.