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 About Me
I recognize that it is probably of at least some importance to you that you get to know
a bit about the person writing this (me).

I grew up knowing that I would one day play Division-1 college soccer. Everything
I did in my childhood and adolescence was preparation for my eventual collegiate
career. In my junior year of high school, I achieved my lifelong dream and verbally
committed to play soccer at St. John’s University in Queens, NY. In November of my
senior year of high school I fractured my tibia and fibula. I underwent Open Reduction
Internal Fixation with an intramedullary rod in my tibia and three screws going from
my tibia to my fibula, two distally at the medial malleolus and one proximally near the
pes anserine, and then started physical therapy.

If you haven’t already figured out how this story ends, my physical therapist not only
helped me recover from my injury, she also gave me my dream back. She helped
me reclaim my self-identity and led me on my eventual career path of becoming a
physical therapist myself. I knew I would never be able to adequately repay her for
all she had done for me, and I also knew that I wanted to dedicate my life to helping
other soccer players achieve their dreams, especially when they might be feeling as
hopeless as I had. I ended up having an amazing experience at St. John’s, and then
went on to Emory University in Atlanta, GA for physical therapy school where I met
my husband, Marc. I currently see patients and clients for both physical therapy and
performance training in person and remotely online in my cash based concierge style
practice. When not working with clients or creating content, Marc and I try to spend
as much time as possible outdoors in nature with our two dogs, Rosie and Kai.

1
 About This Book
Welcome to the Managing the [Un]Injured Soccer Player official eBook!

I designed this course primarily as a self-indulgent project; it’s the course I was look-
ing to take, but it did not yet exist. As both a soccer coach and physical therapist/
performance coach, I found that the research I was reading and learning from was
often not being implemented in the clinic and on the soccer field. I know that it can be
overwhelming to stay up to date on all the research that is put out each year, and it can
often be difficult to find clinical applicability in scientific methods. When I set about
creating this course, I wanted it to serve as a bridge between the literature and clin-
ical practice. I wanted to provide clear, simple, and meaningful ways to practice evi-
dence-based care for soccer players. While this course is specifically geared towards
the management of soccer players, the principles can really be applied to any athlete.

Within this eBook, you will find all the content I present in my course in written for-
mat. You will read about the relevant anatomy, mechanisms of injury, risk factors,
assessment, rehab principles, and sample exercise progressions for some of the most
common injuries incurred by soccer players. You will also learn the physiological
demands of soccer, assess your current return to sport testing criteria and update it
as needed, consider the biomedical, psychological, and social factors contributing to
sports injuries, practice programming through the rehab-performance continuum,
recognize the key components of a successful injury risk reduction program and how
best to implement one with your individual athletes or soccer teams, learn the stages
and progressions of an on field rehab program, and so much more!

2
 Introduction
Over 200,000 anterior cruciate ligament (ACL) surgeries are performed each year.
Most ACL injuries occur from a non-contact or indirect contact mechanism.¹,² The
primary role of the ACL is to prevent anterior tibial translation on the femur and it
also plays a secondary role in providing rotary stability, particularly when the knee is
in a more extended position. The ACL may rupture, then, when the knee is between
0 and 30 degrees of flexion with excessive valgus forces acting through it. The so-
called “position of no return” has been used to describe this position of femoral inter-
nal rotation, hip adduction, and knee valgus in which the ACL will typically tear. The
important thing to remember here is that the knee must be in less than 30 degrees of
flexion in order to tear. We’ll talk more about the importance of this later.

Although not the most common injury, ACL injuries are one of the most significant
amongst soccer players due to the time-loss from sport they cause. The typical treat-
ment course for an athlete with an ACL injury is to undergo ACL Reconstruction
(ACLR), followed by several months of rehabilitation, after which time the athlete ex-
pects to be able to return to their previous level of sport.³ In reality, little over half of
athletes end up returning to their previous level of sport following an ACLR. Further-
more, those who do return to their previous level of sport are now at an increased
risk of having another ACL injury, either to the graft, or the contralateral side.⁴

3
 Introduction Continued
Does everyone who has an ACL tear need surgery?

In making the decision of whether or not to undergo ACLR, one of the things you
would want to know is what the long term outcomes are for people who undergo
ACLR and for those who do not.

A prospective study from the Delaware-Oslo cohort showed that there are very few
differences in course of treatment in the first two years after ACL injury between
patients who chose nonsurgical treatment of ACL injury and those who chose to un-
dergo early ACLR.⁵ Another study, as part of the KANON trial, demonstrated that over
half the ACLRs could be avoided without any major differences in 2 year outcomes.⁶

That same KANON trial group then went on to look at 5 year outcomes in a group of
rehab plus early ACLR vs rehab and optional delayed ACLR and found that delaying
ACLR may have positive long term effects for some patients.⁷

These studies show that there are very few differences in long term outcomes of pa-
tients who choose to undergo early ACLR and those who do not, and that we should
not rule out a non-surgical approach to ACL injury for some patients. The question
now becomes, which patients should be recommended to undergo surgery, and who
should wait?

Another study from the Delaware-Oslo cohort looked for early predictors of a suc-
cessful outcome in those who decided not to undergo ACLR after 2 years. They found
that patients who were older, female, and had good knee function early after an ACL
injury may do better with a non-surgical approach.⁸

The KANON trial studies showed that young, active patients who have a concomitant
meniscus injury, and those whose symptoms seem more severe early after the initial
ACL injury may benefit from beginning exercise therapy prior to considering ACLR.
This may be because the exercise therapy gives the knee a chance to decrease effu-
sion, improve range of motion, and provide a more optimal environment in the knee
for healing (of concomitant injuries) as opposed to undergoing early ACLR which
causes even more trauma to the already injured knee.

It is important to note that the Delaware-Oslo cohort studies have a protocol of a

5-week rehabilitation period immediately after ACL injury, prior to undergoing ACLR.
They have shown that patients who receive early ACLR and those who try non-sur-
gical management (physical therapy for neuromuscular strength training) both im-
prove patient reported outcome measures and knee function after undergoing this 5
week protocol.

Although the research on non-surgical treatment for an ACL tear is still emerging, as
of the time of writing this eBook, the standard of care for athletes who plan on re-
turning to level 1 sports is still to undergo ACLR and rehabilitation.

4
 ACLR Rehabilitation
So maybe it’s actually all in the rehab?

Although the jury may still be out as to whether or not a given patient should under-
go early ACLR, delay ACLR after a period of physical therapy, or treat with exercise
therapy alone, and we still haven’t really taken the plethora of contextual factors
surrounding the decision making process into consideration, one thing we can defin-
itively say is that the current standard and outcomes are simply not good enough.

Maybe what we really need to focus on is getting the rehab program right, regardless
of whether the patient has surgery or not. After an ACL injury, it is important to make
sure that objective measures are being taken appropriately and often enough to help
guide the rehab program and return to sport decision making process. It is also vital
to assess patients’ psychological readiness and patient reported knee function.

Deciding whether or not to undergo ACLR after an ACL surgery can be a difficult
decision. What we now know is that we should not simply rule out a non-surgical or
optional delayed surgical approach, and that maybe patients would do better with be-
ginning an exercise therapy program and then deciding on whether to have surgery
or not. Regardless of the decision, the importance of a good, effective rehabilitation
program cannot be overstated.

ACLR Rehabilitation

For those athletes who do decide to undergo ACLR, the recovery process is lengthy
and challenging both physically and mentally. Once back on the field the last thing an
athlete wants is to have to go through it all over again.

And yet, that is exactly what happens to about 1 in every 4 female athletes within the
first year of their return to cutting and pivoting sports such as soccer.⁹ Further, if an
athlete has had an ACLR, their risk of having another ACL injury is 6 times higher
than an athlete who has never had an ACL injury, and this is likely to occur in the first
two years of return to sport.¹⁰ Although not statistically significant, there is a trend
toward female athletes being more susceptible to a contralateral ACL injury than a
graft rupture.

Can we predict who will have a second ACL injury?

There are studies showing that certain neuromuscular and dynamic postural control
variables are associated with increased risk of a second ACL injury.11,12 These stud-
ies sought to find predictive factors of a second ACL injury at the time of RTS from a
primary ACL injury, and while they did find some associated factors and were able to
identify a “high risk” group, there are still those who suffer a second ACL injury with-
out presence of those factors or without fitting in to that “high risk” category. This
means that although we may be able to identify many athletes who will go on to have
a second ACL injury, we cannot accurately predict all who will, and some of those

5
 ACLR Rehab Continued
who we may deem to be lower risk will still go on to have that second ACL injury.

It has long been reported that younger age is a risk factor for second ACL injury.
However, a recent study from the Delaware-Oslo ACL cohort found that age acts
merely as a proxy for returning to cutting and pivoting sports. The younger athletes
(under the age of 25) are the ones who are most likely to return to these level 1 sports
after a primary ACLR and therefore, are the ones who are most at risk for another
ACL injury. In fact, returning to level 1 sport within a year of primary ACLR was in-
dependently associated with a 6 times higher rate of second ACL injury, and passing
RTS criteria was associated with a 92% reduction in second ACL injury rate. After ad-
justing for returning to level 1 sport in the first year after an ACLR and passing return
to sport (RTS) testing criteria, there was no association between age and second ACL
injury rate.13

In summation, we cannot accurately identify everyone who will go on to have a sec-

ond ACL injury, returning to level 1 sport increases the risk of a second injury, and
passing RTS testing criteria prior to returning to sport decreases that risk. However,
not every study shows that passing RTS testing decreases the risk of second ACL in-
jury and there is still no consensus on what tests should be included in a RTS testing
battery.
IS AGE A RISK
FACTOR FOR 2ND
ACL INJURY?

Returning to level 1 sport

within 1st year after Passing RTS criteria is
primary ACLR is independently associated
independently associated with a 92% lower 2nd ACL
with a 6x higher risk of injury rate
another ACL injury

Younger athletes are twice Younger athletes are more

as likely as older athletes likely to return to level 1
to return to level 1 sports sport without passing RTS
in 1st year after primary criteria
ACLR

After adjusting for RTS in 1st year

and passing RTS criteria, there
was no association between age
and 2nd ACL injury
Grindem H, Engebretsen L, Axe M, Snyder-Mackler L, Risberg MA. Activity and functional readiness, not age, are the critical factors for second anterior
cruciate ligament injury — the Delaware-Oslo ACL cohort study. British Journal of Sports Medicine. 2020:bjsports - 2019. doi:10.1136/bjsports-2019-100623

6
 Return to Sport Testing
Up until the past decade or two, time was usually the sole contributing factor in de-
termining when an athlete was ready to return to sport. Papers by Frank Noyes and
Sue Barber-Westin in the early 90’s are some of the first to describe any objective,
criteria-based measures in RTS testing.14,15 Since then, there has been high variabil-
ity in what constitutes RTS testing, and there does not seem to be a clear set of evi-
dence-based guidelines in what needs to be tested. In order to decide what needs to
be tested, we must first determine the purpose of RTS testing in the first place.

Why do we do it?

The idea behind RTS testing is that it gives us a set of objective measures that tell us
an athlete is prepared to return to their sport. Two recent systematic reviews, how-
ever, have shown us that there is not really a significant association between passing
RTS testing and risk of a secondary injury.16,17 Furthermore, only about a quarter of
athletes actually pass the RTS testing batteries to which they are subjected. Between
the vast majority of athletes who do not pass RTS testing, and the increasingly high
rates of secondary ACL injury, we are left wondering what tests are we doing and
why, what do these tests actually tell us, and what needs to be improved in RTS test-
ing batteries.

What are we testing?

A nationwide survey of American Physical Therapists

aimed to compile what RTS tests are typically done to
clear an athlete to return to unrestricted sports activities.18
Most Physical Therapists reported using strength testing
and functional testing as part of their RTS testing battery.
Grindem et al put forth a RTS testing battery that has been
found to have a sensitivity of 0.90, a negative likelihood
ratio of 0.37, and a diagnostic odds ratio of 3.28.17 This
testing battery includes isokinetic quadriceps strength
testing at 60 degrees per second, four single-legged hop
tests (single leg hop for distance, 6 meter timed hop test,
triple hop, and triple crossover hop tests), and two patient
reported outcome measures (KOS-ADLS and Global Rat-
ing Scale of Perceived Function).19 This study showed that
athletes who pass this testing battery were less likely to
sustain a secondary knee injury. However, since only a small percentage of subjects
actually passed the RTS testing criteria, it is difficult to draw any solid conclusions
from it. This study also found that utilizing both time and criteria-based testing was
useful in determining readiness for RTS. In fact, they found that each month delay in
RTS was associated with a 51% reduction in re-injury risk, up to the 9-month mark.
Furthermore, of all the tests utilized in the testing battery, quad strength limb sym-
metry index (LSI) seemed to be the most predictive of secondary injury. For every 1%
increase in quad strength LSI, they found that there is a 3% decrease in reinjury risk!

7
 RTS Testing Continued
Most Physical Therapists report that Manual Muscle Testing (MMT) is the method
they use to test quadriceps strength LSI. When attempting to differentiate between
85% and 90% LSI, or 90% and 95% LSI, there is absolutely no way that MMT is sen-
sitive enough to give that information. To a large degree, the conversation about
RTS testing can almost end right here. How can we have a further discussion on
the effectiveness of RTS testing when we are not even testing the most basic aspect
effectively? This is the lowest hanging fruit. I understand that not all clinics have an
isokinetic dynamometer – so refer your athletes out for testing. If you cannot do that,
then there are other, more budget-friendly alternatives you can use to give you a
better idea of quad strength LSI. A crane scale can be purchased for about $35 or you
can utilize rep max testing using a leg extension machine.

Hop Tests

The other most utilized criteria in RTS testing batteries is the single-legged hop tests.
Although not all are ubiquitously utilized, the four hop tests that are most common-
ly described are the single leg hop for distance test, the 6-meter timed hop test, the
triple hop test, and the triple crossover hop test. The goal is to be at least 90% sym-
metrical in distance (or time) on the surgical side as the contralateral limb. These
hop tests are meant to test limb function, the idea being that if you can hop as far
(or as fast) on the surgical limb as the non-surgical limb, then you have the same
functional capacity and are therefore ready to return to sports activities. There are a
few problems with this, however. The first one being that there is an intralimb com-
pensation that occurs in functional tasks beginning 3-5 months post-ACLR, and we
cannot see it with the naked eye.20 Instead of loading the knee appropriately to per-
form these hopping and landing tasks, patients are instead shifting the load to the hip
and/or ankle. The problem is that we cannot usually see these compensations occur
without the use of kinematic and kinetic analysis. It has also been found that patients
who achieve >90% LSI in the hop tests actually have decreased performance on both
contralateral and surgical limbs, as compared to healthy controls and the uninjured
limb of patients who have asymmetric hop tests.20,21 This means that some patients
are only achieving symmetry because they are not performing as well on the contra-
lateral limb.

8
 RTS Testing Continued
This leads us to a larger issue with both strength and functional tests. Generally,
throughout the course of rehabilitation, we are focusing our attention on the surgi-
cal limb. This means that the contralateral limb becomes deconditioned, both from
decreased activity, and from a focus on the surgical side. Therefore, when we go to
compare the strength and function of the surgical knee to the contralateral side, we
are really just comparing a post-surgical limb to a deconditioned and detrained limb.

Now, let’s revisit why we perform RTS testing in the first place – to objectively decide
whether or not an athlete is ready to return to sport. So, is what we’re doing actually
doing what we think it’s doing? I would argue that it is not.

What might be better?

With such low rates of passing RTS tests, the rehabilitation program itself first needs
to be addressed. What are we doing (or not doing) in the rehabilitation of a primary
ACL injury that leads to deconditioning of the contralateral limb as well as inter- and
intra-limb compensations? I don’t claim to have all the answers, but I have some
ideas.

First and foremost, we, as a profession, tend to underload our patients. At the crux of
this is understanding sport demands. If we do not know what our athletes need to be
able to perform, then we cannot possibly prepare them appropriately. If we design a
rehabilitation program that appropriately loads and progresses both limbs, applies
basic strength and conditioning principles, and better prepares athletes for the de-
mands they will be facing when they return to sport, then I think we will start to see
improvements in both RTS test passing rates and, more importantly, decreases in
secondary injury rates.

Another issue is that we, as a profession (at least in the US) are not educated enough
in strength and conditioning principles. Our exercise prescription and overall pro-
gram design needs to drastically improve. Collaboration with strength and condition-
ing coaches can have massive benefits for our athletes. This is particularly true in
situations in which an insurance company denies coverage after a certain amount of
visits or months of rehabilitation. Rather than sending your athletes off with a print-
out of band exercises, or worse, clearing them to return to sport at that point, refer
them to a performance training coach who can help them prepare for their sport
demands.

Furthermore, there is a large difference between testing someone’s landing mechan-

ics from a drop jump test in the clinic and how they land and absorb load on a field
while also having to react to where the ball is, where the opponents are, where other
teammates are located, directions from the coach, cheering (or heckling) from the
fans, pressure from the time clock and scoreboard, the weather, and so much more!
As of now, we aren’t testing appropriate items in a closed environment, and then ex-
pect our athletes to be able to perform them in an open environment.

9
 Return to Performance
This needs to change. Reactive testing should be part of a RTS testing battery. We
should be training reactive tasks and cognitive demands throughout the rehabilita-
tion process. I truly believe that augmented and virtual reality can have a positive in-
fluence on athletes’ rehabilitation in this regard, and am hopeful that new technology
and research in this field will enhance our ability to prepare athletes for the demands
of their sport.

It’s easy to be a critic, and I know that ultimately, every clinician wants to do right by
their patients. I understand that so much of this can be out of our control at times. I
also believe that we cannot simply accept the current rates of secondary knee inju-
ry after an ACLR. It’s clear that we have a long way to go, but I think that following a
few, simple guidelines can help get us started…

1. Time – First and foremost, many athletes are returning to sport way too soon after
a primary ACLR. As previously mentioned, the Delaware-Oslo ACL cohort found that
each month that return to sport is delayed, the reinjury risk is reduced by 51% up un-
til the 9 month mark.19 Compounding this problem is that many athletes who return
to sport are not passing RTS testing criteria prior to their return. It would behoove all
involved to extend the rehabilitation program out a few months longer to ensure the
athlete is prepared to meet the demands of their sport.

2. Physical Preparedness – We need to improve the rehabilitation programs so that

we get both legs as strong as possible, as powerful as possible, and ready to face the
demands of the sport. We then need to properly test and assess the demands that the
athlete will face. For soccer players, this means we need to be training and testing
strength, power, RFD, agility, change of direction, acceleration, deceleration, aerobic
capacity, and repeated sprint ability. We also need to test these items with reactive
components. Knowing the key performance indicators (KPIs) allows us to keep the
end goal in mind and then we can reverse engineer the program to meet the athlete
at their current capacity. I will discuss programming from rehab through perfor-
mance more in depth in a future eBook.

I mentioned earlier that intra-limb compensations begin around 3-5 months post-
ACLR and that we cannot usually see this happening without technology.22 This
can make it difficult to ensure that we are training athletes to appropriately load the
surgical knee and quadriceps. I have found that by putting athletes in a split stance
position, as in rear foot elevated split squats (RFESS), the shift from more of a knee
strategy to more of a hip strategy is more evident. We can see the athlete shift back-
wards and have more of an upright shin, or even a negative shin angle. I often have
the athlete perform the RFESS with the nonsurgical side down first, see how they
choose to perform the movement and what their shin angle looks like, and then see
how that differs when they switch to the surgical side. More often than not, I do see
that the athlete will have a more positive shin angle on the non-surgical side than the
surgical side. In order to correct this, I’ll either teach them about shin angles, video
tape them performing the exercise on both sides and show them the difference

10
 Return to Performance
between the two, or place an object like a foam roller in front of their foot and cue
them to touch their knee to the foam roller when performing the exercise. The meth-
od I use depends on the athlete and what cue best serves them. In the picture below
you can see the positive shin angle we are looking for in the RFESS in order to better
load the knee and quads.

I am also a big proponent of

implementing an on field (or
on court) rehabilitation pro-
gram for athletes. In addition
to a sound strength and con-
ditioning program, an on field
rehabilitation program can
help an athlete bridge the gap
between rehabilitation and
performance. An on field reha-
bilitation program helps to add
chaos, puts athletes back in the
environment in which they’ll
be performing, and can help
their psychological readiness
to return to sport. A good pro-
gram that progresses an athlete
through linear movements,
multi-directional movements,
sport-specific skills, and modi-
fied sport training sessions can
help restore movement quality,
improve physical conditioning,
restore sport-specific skills, and
progressively develop chronic
training load.23,24

I have found great benefit in

tracking metrics such as session duration, total distance, max speed, high speed run-
ning distance, accelerations, decelerations, high metabolic load distance, number of
sprints, sprint distance, max and average heart rate, and session RPE during on field
rehab with the soccer players I work with. Tracking these metrics allows me to grad-
ually progress their program and objectively ensure that the athlete is prepared to
face the demands of their sport. The on field rehab program and the end goal of these
metrics will vary from individual to individual, and will be covered more in depth
in the On Field Rehabilitation eBook that will be released in a few months. In short,
the athlete’s sport, competition level, team tactics, playing position, and individual
factors such as the player’s strengths and weaknesses will dictate their KPIs and the
demands placed on them and therefore, what their program will look like.

11
 Return to Performance

3. Psychological Readiness – An athlete may have waited >9 months and may pass all
the strength and functional tests, but if they do not feel confident in their knee, if they
do not feel ready to return to sport, then we have no business clearing them. Psycho-
logical readiness has been associated with secondary injury after ACLR , and we need
to properly assess it.25 There are a few patient reported outcome measures that have
been utilized in the literature (KOS-ADLS, IKDC-10, GRSPF, ACL-RSI) but as of now,
there is no clear consensus on which is the best to use. Personally, I like the ACL-RSI
when working with patients post-ACLR. However, using any of these tests is better
than using none, and it cannot be overstated how important it is to assess psychologi-
cal readiness to RTS.

Rehab professionals working with the athletic population are uniquely positioned to
assess the psychological and emotional status of injured athletes. It is important to
recognize that while it is completely normal and natural for an athlete to experience a
variety of emotional responses to injury, there can be times in which this response is
abnormal and warrants further discussion and/or referral to sports psych. It is im-
portant, therefore, that we recognize and understand what a normal emotional re-
sponse might look like.

12
 Psychological Readiness
Morrey et al described an inverted “U” shaped emotional response in athletes
throughout the rehabilitation process in which they begin with negative emotions
of anger and disgust, then begin to develop more positive emotions of joy and ex-
citement throughout the rehabilitation process, and then another dip back into the
negative emotions of fear and anxiety right around the time of return to sport.26 It’s
important to understand that it is completely normal and natural for athletes to ex-
perience negative emotions when they are injured, and again when they are about to
return to sport. There are times, however, in which the athlete becomes consumed
by the negative emotions, loses their motivation or desire to compete, or plays the
victim. There are also athletes who are overly optimistic and therefore may not take
their rehabilitation seriously enough or set realistic goals for themselves. This is why
I’m such a huge proponent of getting to know your athletes and establishing a good
rapport with them. If you have a good insight into their typical behavior and person-
ality quirks, then you can more readily recognize when they are showcasing an atypi-
cal emotional and behavioral response to injury.

13
 Psychological Readiness
It is important to recognize the emotional and psychological responses of your ath-
letes because it is associated with successful return to sport. Indeed, athletes who
have less fear of reinjury have faster return to sport times. Female sex, not setting re-
alistic rehab goals, and negative outlook and attitude are all predictive of unsuccessful
return to sport.27 So how can we help our athletes with the emotional and psychologi-
cal aspects of rehabilitation?

Set well-defined, attainable goals. - As clinicians and rehab professionals, it’s import-
ant that we have the end in mind and keep that overall big picture as a guide for the
rehab program. For the athlete, however, breaking that down into smaller, short-term
goals is much more empowering than the longer-term goals.

Give control where appropriate. - There are many ways to give the athlete some
control over their program. One way I like to do this is by allowing them to choose
between two different exercises that provide the same, or a similar, training stimulus.
For example, if I want to prescribe an exercise that loads the quads, I can allow the
athlete to choose between spanish squats or goblet squats. You can also allow them
to choose something that isn’t necessarily a priority. I’ll often do this by allowing the
athlete to choose whatever “core” exercise they want to do at the end of the session.

Listen to and support them. - It’s important that the athlete feels they can trust you.
One of the first conversations I have with an injured athlete is about their goals and
letting them know that I want the same exact things they do. I want them to get back
to their sport as soon as they can. I want them to be a better athlete at the end of their
program than they were before their injury. When the athlete knows that you ulti-
mately want the same things they do, then it makes it easier to have some of the diffi-
cult conversations that may come up throughout the course of their rehabilitation.

4. Applying Principles of Motor Learning - Finally, we need to be cognizant of the

role the nervous system plays in all of this. An ACL tear is not only a knee injury, but
also a disruption to the nervous system. Some of the neuroplastic changes we see in
association with ACL injuries are errors of estimation, increased reliance on visual
feedback, and decreased motor cortex excitability. There are some common compen-
sations that we tend to see in athletes after an ACLR such as decreased knee flexion
during deceleration and change of direction tasks. These negative movement com-
pensations and neuroplastic changes may even be further embedded by our current
rehabilitation practices.

The ACL contains receptors that gather information regarding the position of the
joint and relay it to the spinal cord and brain for further processing. When the ACL is
injured, those messages become disrupted. The brain, therefore, is not receiving the
information it needs to respond to loads and plan for and produce movement. The
brain is incredibly adaptable and responds to this decreased afferent information by
increasing its reliance on visual feedback.28

14
 Neuroplasticity
Athletes need to be able to interact with the environment around them including the
surface they are playing on, the ball, opponents, teammates, the space on the field, the
direction of the goal, and more. When the visual centers of the brain are being utilized
to help process information about the knee and how it is moving, there is decreased
capacity to process important information about the environment. This may impair
the performance of the athlete and potentially increase their risk of reinjury by affect-
ing their ability to react to what’s going on around them.

In addition to decreased afferent information from the ACL-injured knee to the ner-
vous system, there is also decreased cortical excitability after ACLR for quadriceps
contractions. This means that it takes more stimulus to produce a conscious con-
traction of the quadriceps muscles. In order to adapt to this, the brain increases its
activation in the motor planning areas of the brain. Patients who have undergone
ACLR have decreased motor cortex excitability which means that greater motor cortex
activation is required to achieve a motor output.29 There are also neuroplastic changes
affecting both limbs of patients who had undergone ACLR when compared to healthy
controls.30 This all means that when an athlete returns to sport after an ACLR, areas
of the brain typically used for helping the athlete to interact with and respond to their
ever-changing environment are instead being used to help with joint proprioception
and driving motor outputs which may put the athlete at an increased risk of reinjury.

ACL INJURY

'd afferent information 'd cortical excitability

'd reliance on visual feedback 'd motor planning activity

There are a few ways that we might be able to address these neuroplastic changes
throughout the rehabilitation process…

15
Motor Learning Principles
What many of us fail to realize is that one of our main roles as rehab professionals is
that of a teacher. The athlete needs to learn how to perform certain tasks again with-
out the compensations often seen after an ACLR that may put them at increased risk
of reinjury. When an athlete goes back to their sport, they need to be able to interact
with the environment, multi-task, and perform the sport with automaticity. It’s no
good to the athlete if they’re able to perform a perfect squat in front of a mirror in the
clinic if they cannot efficiently land from a jump on the field or court. Rather than be-
ing satisfied with short term technique success, we should be seeking true long-term
motor learning. In order to effectively achieve this, we need to be cognizant of ways
that we can utilize our cues, feedback, and the environment in order to drive implicit
learning versus explicit learning.31

Before we delve into how we can help drive the motor learning process, we should
first discuss why we need to strive for implicit learning over explicit learning.

Implicit learning is IMPLICIT

when a skill is learned
in such a way that you LEARNING
cannot be consciously
aware of how you are
performing it. For exam-
ple, when you learn to
ride a bicycle, you don’t
go to a special bicycle CUES FEEDBACK ENVIRONMENT
riding coach, clinic, or
camp. You do not have
someone program a specific progression for you with instructions along the way such
as, “push your right foot down into the pedal as you bring your left hip up into flexion”.
Instead, you sit on the seat, hold onto the handlebar, and someone pushes you along
until you catch on. Sure, you may fall a few times, but the entire process is reflective
of implicit learning. A huge benefit of implicit learning is that it is long-lasting skill ac-
quisition, and not a transient success. You could go years without riding a bicycle, and
yet as soon as you get on one again, you automatically know what to do.

When an athlete has a particularly stellar performance, they often report feeling as
though they were “in the zone”. This means that they were able to tune out distrac-
tions, obliterate pressure, multi-task, and perform under fatigue. It is quite impossible
to do these things when you are constantly in your own head trying to think about
how you should be performing each and every movement. No athlete is going to per-
form well if they are thinking about how much knee flexion they have after their fol-
low through from a shot on goal. And yet, this is exactly what we are teaching them in
their rehabilitation programs. In fact, Rich Masters has done some great work in the
field of implicit learning showing that having too much conscious control of move-
ment disrupts automaticity, and those who place too much conscious control in their
movements end up performing worse under pressure.32

16
Motor Learning Principles
Cues

We’ve likely all seen an athlete after an ACLR go to perform a squat and shift off their
surgical side onto the uninvolved leg. A common cue given in this scenario is to place
a mirror in front of the patient so that they can see when they shift and hopefully
correct it. While this cue may be helpful initially, it may also be driving that increased
dependency on visual cues for proprioceptive information. Perhaps taking the mirror
away eventually, having them perform the task with their eyes closed, or even utiliz-
ing stroboscopic goggles for vision obstruction could help to improve proprioceptive
awareness while decreasing the reliance on visual feedback.

Even an exercise as simple as a straight leg raise is repeated practice in explicit learn-
ing. We tell the athlete to squeeze their quads and focus on keeping their knee straight
as they perform the movement. We are literally teaching the athlete to do the very
things we do not want them to actually do when they return to sport – internal focus
of attention and visual dependency to perform a very simple movement task. Instead,
we can have the athlete perform the task with their eyes closed, utilize augmented or
virtual reality to make the task more meaningful and specific to them, or use of an ex-
ternal focus of control such as a laser pointer or metronome to guide the movement.

The verbal cues we give are another thing to consider. When we give cues such as
“bend your knee more”, we may be further contributing to the visual dependency and
an internal focus of attention by forcing the athlete to look at how their body is mov-
ing in relation to itself. Giving a cue that shifts the focus outside of the body (“land on
the markers”) may help free up some of the cortical resources for more complex tasks
such as reaction and anticipation. Changing cues to have more of an external focus
of attention has been shown to be effective in producing the desired movements and
can help improve the motor learning process.

Feedback

This goes for how we give instructions and feedback as well. Giving an athlete cues or
directions such as, “when you land, land with equal weight on each leg, make initial
contact with the balls of your feet, then sink down into your heels as you bend your
knees and go into hip flexion” may be taking up too much processing power in the
premotor cortex areas of the brain and then when they go to perform that task in an
open environment, they are unable to respond to the field, ball, opponents, and team-
mates around them. In my own practice, I usually begin by giving a very simple in-
struction (“jump off the box and land on this line”), maybe perform a demonstration,
and then I allow the athlete to perform the movement with their chosen movement
pattern. This shows me what their preferred movements are and what needs to be
coached further.

When we are working with athletes, often one of the more difficult things to do is to
sit back and allow them to perform without constant feedback. We want to

17
Motor Learning Principles
help them complete the given task perfectly, and feel that we are only doing our jobs
when we try to coach up every tiny flaw. We should see the amount and the rate at
which we provide feedback as a means of progression. Initially, it might be more
beneficial to give more consistent feedback, but we should gradually limit the amount
of feedback we give. One thing I like to do once an athlete is comfortable performing
a task is asking them at the end of a set how they think they performed. When we ask
them, “how did that go?” or, “how do you think you did?”, we are helping to drive im-
plicit learning and shifting the locus of control back to them and away from us.

When I was a youth soccer player, I distinctly remember having coaches who would
miss all the good things I did and only come give me feedback when I made a mistake.
I used to think to myself that I was so unlucky to only be seen when I did something
wrong. Having been on the other side of things as both a coach and a physical thera-
pist, I now see that my youth coaches most likely did see the good things I was doing,
but only felt the need to help me with the mistakes I made. I still catch myself doing
this sometimes. We want to help our athletes get better and so we search for mistakes
that we can help them fix and improve. However, athletes tend to respond more fa-
vorably to positive feedback rather than negative feedback. It is far more powerful to
an athlete to be told when they have succeeded and asked to replicate that. One way
I like to utilize this in the clinic is by noticing a well-executed rep or movement and
then saying, “that was perfect, do every one exactly like that one”. Giving feedback in
this way not only provides the positive feedback they require, but also helps to drive
implicit learning.

Environment

Typically, athletes are seen by physical therapists in a clinical setting while they are
rehabilitating after an ACLR. There is a big difference between performing a move-
ment task in the safety of a closed clinical setting and in the unpredictable, open set-
ting of a field or court. Neuromuscular control deteriorates when the distractions of
opponents or a ball are added, so we need to prepare athletes for that. The easiest and
most obvious way to address this is to take the athlete onto the field for some on-field
rehab where these other components are gradually added to the program. I am a big
proponent of on-field rehab and see the benefit of it regularly with my clients. I also
understand that this is simply not realistic for many, if not most physical therapists.

Other ways to better prepare athletes for the open environment are to add reactive
training and cognitive dual-tasking. Reactive training can be as simple as a balloon
toss, juggling a soccer ball, or accelerating, decelerating, and changing directions in
response to a verbal or visual command or cue. Cognitive dual-tasking can be per-
formed by having the athlete perform an upper body task (catching a tennis ball)
while performing a desired lower body movement (side shuffling). I like to have the
athletes I work with perform math problems or answer trivia questions while per-
forming soccer technical work. Be creative!

Being aware of the neuroplastic changes that result from an ACL injury and

18
 Summary
subsequent ACLR can potentially make an impact on the rates of secondary injury we
are currently witnessing. Don’t forget that we still need to get the athlete really strong
prior to returning to sport, and being cognizant of how we can address these neuro-
plastic changes can help us to design a more complete and comprehensive rehabilita-
tion and risk reduction program.

Summary

In summary, our athletes are at increased risk of a second ACL injury once they re-
turn to sport after a primary ACLR. They are going back to sport too soon and are
not meeting functional requirements prior to returning to sport. Our return to sport
testing criteria must improve by better assessing an athlete’s ability to perform sport
demands. Even more importantly, our rehabilitation programs need to be better. We
should be adequately loading athletes, training both limbs, progressively adding cha-
os, and moving from a closed training environment to an open one. This can be done
through an on field rehabilitation program which not only helps athletes become
physically prepared for their sport, but also may help with psychological readiness.
We also must not neglect the nervous system’s role in this, and aim to drive implicit
learning through our cues, feedback, and the environment.

19
Thanks for Reading!
Here is a look ahead at the future eBooks

Hamstring Strains
Hip and Groin Injuries
Physiological Demands of Soccer
Return to Sport Decision Making
Programming on the Rehab-Performance Continuum
Injury Risk Reduction Programs
On Field Rehab

nicolesurdykaphysio.com

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 References
1. Della Villa F, Buckthorpe M, Grassi A, et al. Systematic video analysis of ACL injuries in professional
male football (soccer): injury mechanisms, situational patterns and biomechanics study on 134 con-
secutive cases. Br J Sports Med. June 2020. doi:10.1136/bjsports-2019-101247
2. Waldén M, Krosshaug T, Bjørneboe J, Andersen TE, Faul O, Hägglund M. Three distinct mechanisms
predominate in non-contact anterior cruciate ligament injuries in male professional football players: a
systematic video analysis of 39 cases. Br J Sports Med. 2015;49(22):1452-1460.
3. Webster KE, Feller JA. Expectations for Return to Preinjury Sport Before and After Anterior Cru-
ciate Ligament Reconstruction. The American Journal of Sports Medicine. 2019;47(3):578-583.
doi:10.1177/0363546518819454
4. Ardern CL, Taylor NF, Feller JA, Webster KE. Fifty-five per cent return to competitive sport following
anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis
including aspects of physical functioning and contextual factors. Br J Sports Med. 2014;48(21):1543-
1552.
5. Grindem H, Eitzen I, Engebretsen L, Snyder-Mackler L, Risberg MA. Nonsurgical or Surgical Treat-
ment of ACL Injuries: Knee Function, Sports Participation, and Knee Reinjury: The Delaware-Oslo ACL
Cohort Study. J Bone Joint Surg Am. 2014;96(15):1233-1241.
6. Frobell RB, Roos EM, Roos HP, Ranstam J, Lohmander LS. A randomized trial of treatment for acute
anterior cruciate ligament tears. N Engl J Med. 2010;363(4):331-342.
7. Filbay SR, Roos EM, Frobell RB, Roemer F, Ranstam J, Lohmander LS. Delaying ACL reconstruction
and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an explorato-
ry analysis of the KANON trial. Br J Sports Med. 2017;51(22):1622-1629.
8. Grindem H, Wellsandt E, Failla M, Snyder-Mackler L, Risberg MA. Anterior Cruciate Ligament In-
jury-Who Succeeds Without Reconstructive Surgery? The Delaware-Oslo ACL Cohort Study. Orthop J
Sports Med. 2018;6(5):2325967118774255.
9. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of contralateral and ipsilateral an-
terior cruciate ligament (ACL) injury after primary ACL reconstruction and return to sport. Clin J Sport
Med. 2012;22(2):116-121.
10. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years
After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567-1573.
11. Paterno MV, Schmitt LC, Ford KR, et al. Biomechanical measures during landing and postural stabil-
ity predict second anterior cruciate ligament injury after anterior cruciate ligament reconstruction and
return to sport. Am J Sports Med. 2010;38(10):1968-1978.
12. Paterno MV, Huang B, Thomas S, Hewett TE, Schmitt LC. Clinical Factors That Predict a Second ACL
Injury After ACL Reconstruction and Return to Sport: Preliminary Development of a Clinical Decision
Algorithm. Orthop J Sports Med. 2017;5(12):2325967117745279.
13. Grindem H, Engebretsen L, Axe M, Snyder-Mackler L, Risberg MA. Activity and functional
readiness, not age, are the critical factors for second anterior cruciate ligament injury — the Dela-
ware-Oslo ACL cohort study. British Journal of Sports Medicine. 2020:bjsports - 2019. doi:10.1136/
bjsports-2019-100623
14. Noyes FR, Barber SD, Mangine RE. Abnormal lower limb symmetry determined by function hop
tests after anterior cruciate ligament rupture. The American Journal of Sports Medicine. 1991;19(5):513-
518. doi:10.1177/036354659101900518
15. Barber SD, Noyes FR, Mangine R, DeMaio M. Rehabilitation after ACL reconstruction: function test-
ing. Orthopedics. 1992;15(8):969-974.
16. Webster KE, Hewett TE. What is the Evidence for and Validity of Return-to-Sport Testing after Ante-
rior Cruciate Ligament Reconstruction Surgery? A Systematic Review and Meta-Analysis. Sports Med.
2019;49(6):917-929.

21
 References
17. Losciale JM, Zdeb RM, Ledbetter L, Reiman MP, Sell TC. The Association Between Passing Return-
to-Sport Criteria and Second Anterior Cruciate Ligament Injury Risk: A Systematic Review With Me-
ta-analysis. J Orthop Sports Phys Ther. 2019;49(2):43-54.
18. Greenberg EM, Greenberg ET, Albaugh J, Storey E, Ganley TJ. Rehabilitation Practice Patterns Fol-
lowing Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists. J Orthop Sports
Phys Ther. 2018;48(10):801-811.
19. Grindem H, Snyder-Mackler L, Moksnes H, Engebretsen L, Risberg MA. Simple decision rules can
reduce reinjury risk by 84% after ACL reconstruction: the Delaware-Oslo ACL cohort study. Br J Sports
Med. 2016;50(13):804-808.
20. Sigward SM, Chan M-SM, Lin PE, Almansouri SY, Pratt KA. Compensatory Strategies That Reduce
Knee Extensor Demand During a Bilateral Squat Change From 3 to 5 Months Following Anterior Cruci-
ate Ligament Reconstruction. J Orthop Sports Phys Ther. 2018;48(9):713-718.
21. Wren TAL, Mueske NM, Brophy CH, et al. Hop Distance Symmetry Does Not Indicate Normal Land-
ing Biomechanics in Adolescent Athletes With Recent Anterior Cruciate Ligament Reconstruction. J
Orthop Sports Phys Ther. 2018;48(8):622-629.
22. Sigward SM, Chan M-SM, Lin PE, Almansouri SY, Pratt KA. Compensatory Strategies That Reduce
Knee Extensor Demand During a Bilateral Squat Change From 3 to 5 Months Following Anterior Cruci-
ate Ligament Reconstruction. J Orthop Sports Phys Ther. 2018;48(9):713-718.
23. Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field Rehabilitation Part 1: 4 Pillars of
High-Quality On-field Rehabilitation Are Restoring Movement Quality, Physical Conditioning, Restor-
ing Sport-Specific Skills, and Progressively Developing Chronic Training Load. J Orthop Sports Phys
Ther. 2019;49(8):565-569.
24. Buckthorpe M, Della Villa F, Della Villa S, Roi GS. On-field Rehabilitation Part 2: A 5-Stage Program
for the Soccer Player Focused on Linear Movements, Multidirectional Movements, Soccer-Specific
Skills, Soccer-Specific Movements, and Modified Practice. J Orthop Sports Phys Ther. 2019;49(8):570-
575.
25. Ardern CL, Österberg A, Tagesson S, Gauffin H, Webster KE, Kvist J. The impact of psychological
readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction.
Br J Sports Med. 2014;48(22):1613-1619.
26. Morrey MA, Stuart MJ, Smith AM, Wiese-Bjornstal DM. A Longitudinal Examination of Athletesʼ
Emotional and Cognitive Responses to Anterior Cruciate Ligament Injury. Clinical Journal of Sport
Medicine. 1999;9(2):63-69. doi:10.1097/00042752-199904000-00004
27. Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors asso-
ciated with returning to sport following injury. Br J Sports Med. 2013;47(17):1120-1126.
28. Grooms DR, Page SJ, Nichols-Larsen DS, Chaudhari AMW, White SE, Onate JA. Neuroplasticity As-
sociated With Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2017;47(3):180-
189.
29. Grooms D, Appelbaum G, Onate J. Neuroplasticity following anterior cruciate ligament inju-
ry: a framework for visual-motor training approaches in rehabilitation. J Orthop Sports Phys Ther.
2015;45(5):381-393.
30. Lepley AS, Gribble PA, Thomas AC, Tevald MA, Sohn DH, Pietrosimone BG. Quadriceps neural
alterations in anterior cruciate ligament reconstructed patients: A 6-month longitudinal investigation.
Scand J Med Sci Sports. 2015;25(6):828-839.
31. Gokeler A, Neuhaus D, Benjaminse A, Grooms DR, Baumeister J. Principles of Motor Learning to
Support Neuroplasticity After ACL Injury: Implications for Optimizing Performance and Reducing Risk
of Second ACL Injury. Sports Med. 2019;49(6):853-865.
32. Masters R, Maxwell J. The theory of reinvestment. International Review of Sport and Exercise Psy-
chology. 2008;1(2):160-183. doi:10.1080/17509840802287218

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