Phase 3: Running, Agility, and Landings
Aim:
As with primary ACL injuries, the majority of secondary ACL injuries occur through non-contact mechanisms (Wright et al, 2010). This strongly suggests that there are underlying intrinsic, neuromuscular factors contributing to the injury risk. Multiple studies have demonstrated the effectiveness of neuromuscular retraining in the prevention of secondary ACL injuries (Hewett et al, 1996; Hewett et al, 1999; Myer et al, 2007). This is believed to be related to enhancing athletes function and movement behaviours early after the injury, as well as improving function and movement behaviours following ACLR (Chmielewski et al, 2005; Risberg et al, 2007; Di Stasi et al, 2012).
To facilitate the athlete’s progression through the challenging running, agility, and landings phase, we have developed the kNee Eeducation for Healthy Active Bodies (NE HAB) as a means of providing internal and external feedback and encouraging the athlete to assess their own technique. This program is designed to teach the athlete about how to effectively recruit lower fibers of gluteus maximus, how to avoid dynamic knee valgus, and how to critique their own jumping, landing and cutting patterns.
NE HAB consists of five different functional activities evaluating the athlete’s knee function during the rehabilitation period. Both the patient and the therapist independently and simultaneously evaluate the athlete’s ability to perform functional tasks. The NE HAB program is incorporated to educate the athlete about correct landing, cutting, running, hopping, and jumping techniques, neuromuscular control, and correct muscle activation; allowing them to assess their own functional performance. NE HAB will be conducted by the therapist at monthly intervals during phase 3 to provide feedback on technique and areas to develop.
Phase 3 NE HAB
Test | Description (see videos here) | Therapist Points | Athlete Points |
Eccentric step downs | The subject stands on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension. | ||
Single leg squat | Stand on one leg with arms crossed. Squat down to 60˚, then return to start position | ||
Running man with calf raise | Stand on one leg, hands by side. Bend forward from hips while simultaneously bending knee. Reach one arm forward with torso parallel with the ground and same leg stretched behind you. Return to start position, finishing with a calf raise. | ||
Bounding in place | Jump from one leg to the other straight up and down, progressively increasing rhythm and height | ||
Cone jumps | Double leg jump with feet together. Jump side to side over cones quickly. Repeat forward and backward |
Phase 4 NE HAB
Test | Description (see videos here) | Athlete Points | For scores <10 please give a reason |
Eccentric step downs on foam | The subject stands on a pillow or cushion on a 20 cm step on one leg and has 30 seconds to reach forward and touch the ground lightly with their heel and return to full knee extension. | ||
Single leg squat | Stand on one leg with arms crossed. Squat down to 90˚, then return to start position | ||
Running man with calf raise on mini tramp | Stand on mini tramp on one leg, hands by side. Bend forward from hips while simultaneously bending knee. Move arms in running pattern coordinated with legs. Return to start position, finishing with a calf raise. | ||
Bound and hold | Jump from one leg to the other forwards and backwards, holding the landing for 3 seconds each time. Repeat side to side. | ||
Cone jumps | Single leg hop side to side over cones quickly. Repeat forward and backward. |
Qualitative analysis of closed kinetic chain exercises
QACKCE | Closed Kinetic Chain Exercises | Left | Right |
Arm strategy | Excessive arm movement to balance | ||
Trunk alignment | Leaning in any direction | ||
Pelvic plane | Loss of horizontal plane Excessive tilt or rotation |
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Thigh motion | WB thigh moves into hip adduction NWB thigh not held in neutral |
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Knee position | Patella pointing towards 2nd toe (noticeable valgus) Patella pointing past inside of foot (significant valgus) |
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Steady stance | Touches down with NWB foot Stance leg wobbles noticeably Total |
Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013
Qualitative analysis of open chain exercises
QAOKCE | Plyometric Exercises | Left | Right |
Arm strategy | Excessive arm movement to balance | ||
Trunk alignment | Leaning in any direction | ||
Pelvic plane | Loss of horizontal plane Excessive tilt or rotation |
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Thigh motion | WB thigh moves into hip adduction NWB thigh not held in neutral |
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Knee position | Patella pointing towards 2nd toe (noticeable valgus) Patella pointing past inside of foot (significant valgus) |
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Landing stance | Touches down with NWB foot Noticeably wobbly during landing Total: |
Modified from “Task based rehabilitation protocol for elite athletes following Anterior Cruciate ligament reconstruction: a clinical commentary” Herrington et al, 2013
Sample Exercise Session Phase 2 Home Program
Exercise | Sets / Duration | Resistance | Reps | Recovery |
WARM UP |
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Cross-trainer/ Treadmill/ Bike | 5 Mins | 90 secs | ||
PEP style dynamic warm up (see appendix B) | 10 Mins | 30 secs | ||
STRENGTH/PROPRIOCEPTION |
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Kettlebell swings | 30 secs | 4 | 90 secs | |
Power leg press | 3 | 10 | 90 secs | |
Single leg running man progression | 2 | 20 | 90 secs | |
Bulgarian lunges | 3 | 10 | 90 secs | |
Nordic hamstrings | 3 | 10 | 90 secs | |
Bosu trunk extensions | 3 | 20 | 90 secs | |
Single leg Romanian deadlifts | 3 | 10 | 90 secs | |
Bosu v-sit crunches | 3 | 20 | 90 secs | |
Lunge jumps | 2 | 20 | 20 secs | |
Scissor jumps | 2 | 20 | 20 secs | |
Depth jumps | 2 | 20 | 20 secs | |
Zig zag running | 2 | 6 | 20 secs | |
3 point lateral bound and hold | 2 | 6 | 20 secs | |
COOL DOWN |
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Mini tramp jog | 10 Mins | |||
ROM (as required) |
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ITB foam roller | 20 up and back | Alternate |
Sample Training Program Phase 3
TYPE | VENUE | MON | TUE | WED | THU | FRI | SAT | SUN |
Prescribed program | Home / Gym | 60 Mins | 60 Mins | 60 Mins | LTAKI 20 mins | |||
Cardio | Pool / Bike / Run | 45 Mins | 45 Mins | 45 Mins |
Outcome Measures and Goals for Progression to Phase 4:
Measure | Test description & Reference | Goal -> Purpose/ reasoning |
Star Excursion Balance Test (SEBT) | The athlete must maintain a base of support on one leg, while using the other leg to reach as far as possible in 3 different directions. A composite score is obtained for each leg from which the limb symmetry index (LSI) is then calculated (Herrington et al, 2009) | Symmetrical reach in all directions , >95% compared with other side Test for balance in multiple planes |
Single Leg Hop for Distance | The athlete stands on one leg and hops as far forward as possible, landing on the same leg. The landing is maintained for a minimum of 2 seconds (Noyes et al, 1991). | >90% compared with other side |
Triple Cross-Over Hop Test | The athlete performs three hops as far as possible crossing over a 15cm wide strip, holding the final landing for 2 seconds (Noyes et al, 1991) | >90% compared with side |
Landing Error Scoring System | The subject jumps forward from a 30cm high box with both feet a distance equal to half their body height. Upon landing the athlete immediately jumps vertically as high as possible. The task is repeated until the following has been assessed (Padua et al, 2009):
Sagittal (Side) View
Yes=0, No=1
Coronal (Frontal) View
Overall impression |
A score of ‘Excellent’ is required. Excellent (0-3) Good (4-5) Moderate (6) Poor (7 or greater) Test for stability and range through trunk and lower extremity during landing |
Single Leg Press | 1RM as tested on an incline leg press. Starting with knee fully extended, the weight is lowered until approximately 90˚ of knee flexion, then returned to full extension (ACSM | 2 x body weight Ensure adequate strength for injury prevention |
Prone Leg Curl | Athlete lying prone with knee in full extension. A valid test is when the athlete can control the weight through full range of flexion and return to start position (Kraemer & Fry, 1995). | HS/Quad ratio >70% Test for quads dominance |
Functional Score | IKDC Subjective Knee Evaluation Form (Irrgang et al, 2001) | Sore > 70 |