Monitoring the Return to Sport Transition After ACL Injury: An Alpine Ski Racing Case Study

Matthew J Jordan, Nathaniel Morris, Mike Lane, Jeremiah Barnert, Katie MacGregor, Mark Heard, Sarah Robinson, Walter Herzog, Matthew J Jordan, Nathaniel Morris, Mike Lane, Jeremiah Barnert, Katie MacGregor, Mark Heard, Sarah Robinson, Walter Herzog

Abstract

Alpine ski racing is an extreme sport and ski racers are at high risk for ACL injury. ACL injury impairs neuromuscular function and psychological readiness putting alpine skiers with ACL injury at high risk for ACL reinjury. Consequently, return to sport training and testing protocols are recommended to safeguard ACL injured athletes against reinjury. The aim of this paper was to present a real-world example of a return to sport training plan for a female elite alpine ski racer who sustained an ACL injury that was supported by an interdisciplinary performance team (IPT) alongside neuromuscular testing and athlete monitoring. A multi-faceted return to sport training plan was developed by the IPT shortly after the injury event that accounted for the logistics, healing, psychological readiness, functional milestones, work capacity and progression to support the return to sport/return to performance transition. Neuromuscular testing was conducted at several timepoints post-injury. Importantly, numerous pre-injury tests provided a baseline for comparison throughout the recovery process. Movement competencies and neuromuscular function were assessed, including an evaluation of muscle properties (e.g., the force-velocity and force-length relationships) to assist the IPT in pinpointing trainable deficits and managing the complexities of the return to sport transition. While the athlete returned to snow 7 months post-injury, presenting with interlimb asymmetries below 10%, functional and strength deficits persisted up to 18 months post-injury. More research is required to establish a valid return to sport protocol for alpine ski racers with ACL injury to safeguard against the high risk for ACL reinjury.

Keywords: ACL reinjury; knee injuries; quadriceps/hamstrings strength; training load; vertical jump asymmetry; vertical jump power.

Copyright © 2020 Jordan, Morris, Lane, Barnert, MacGregor, Heard, Robinson and Herzog.

Figures

Figure 1
Figure 1
Milestone and timeline progression used in the return to sport training plan.
Figure 2
Figure 2
A probability-based risk profile using three different quadriceps limb symmetry index thresholds is presented to contextualize the uncertainty surrounding the return to sport transition after ACL reconstruction surgery. Thresholds were chosen to reflect known associations between the quadriceps limb symmetry index and risk of ACL reinjury (Grindem et al., 2016).
Figure 3
Figure 3
Weekly (A) and monthly (B) internal workloads (sessional rating of perceived exertion method—sRPE) in arbitrary units (AU). Vertical lines represent time points of interest. An instance of a planned recovery microcycle is highlighted (circle). (C) Depicts the count of logged training sessions, including periods when no logging occurred. Periods when no logging occurred are not shown in (A,B).
Figure 4
Figure 4
Target neuromuscular milestone and workload progressions post ACL reconstruction surgery. CMJ, Countermovement Jump; SJ, Squat Jump; RFD, Rate of Force Development; RTS, Return to Sport; Eccentrric Decel, Eccentric Deceleration.
Figure 5
Figure 5
Squat jump (SJ) and countermovement jump (CMJ) force-time asymmetry assessments pre-injury, post-injury, at return to sport (RTS) and 18 months post-surgery (A: CMJ Eccentric Deceleration Phase; B: CMJ Concentric Phase; C: SJ Early Takeoff Phase; D: SJ Late Takeoff Phase). Data are shown as the five-jump mean asymmetry index ± SD (positive value = ACLR limb dominance; negative value = contralateral limb dominance). SJs demonstrating a small amplitude countermovement were discarded from the analysis. *First asymmetry test post-injury; # observation of shift in the interlimb asymmetry at teh return to sport phase.
Figure 6
Figure 6
Squat jump (SJ) asymmetries in the early takeoff phase (initiation of jump to the peak vertical ground reaction force) and late takeoff phase (peak vertical ground reaction force to toe-off) over the 80 s repeated SJ test. A comparison is made between pre-injury tests and post-injury tests. A decline in late takeoff phase asymmetry (i.e. increased symmetry) with fatigue (i.e., Set 1 vs. Set 4) was observed post-injury reflecting a decline in force generated by the contralateral limb.
Figure 7
Figure 7
(A–D) Depict lower body mechanical muscle function assessed in the countermovement jump (CMJ) and squat jump (SJ). Shaded gray zone depicts the post-injury period. Thick horizontal dashed line shows the mean pre-injury value. Thin dashed line depicts trendline over the testing period. To highlight the importance of considering the strength of each limb independently alongside a measure of interlimb asymmetry, the ACLR limb stiffness (+ symbol) and non-injured limb stiffness (• symbol) are shown alongside the total limb stiffness (o symbol). While the interlimb asymmetry in limb stiffness was negligible at the 18 months post-injury time point, it can be seen that the total limb stiffness had still not fully recovered to the pre-injury mean value. (E) Shows the CMJ takeoff velocity vs. load profile and (F) shows the CMJ eccentric deceleration impulse vs. load profile in the post-injury testing period.
Figure 8
Figure 8
Recovery of the isometric knee extensor/knee flexor maximum torque (A), rate of torque development—RTD (B), leg press maximum force (C), and leg press rate of force development—RFD (D) in the post-injury period. A decrease in the non-injured limb knee extensor maximal torque and RTD was observed through to the 18 months timepoint. Hamstring and quadriceps RTD remained depressed compared to maximal torque at 18 months post-injury. A small interlimb asymmetry in leg press maximum force and RFD was noted at 18 months post-injury.

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