Phase 3: Running, Agility, and Landings

Aim:

  • Strength and neuromuscular progressions
  • Dynamic postural stability
  • Initiate agility, change of direction and crossover drills
  • Deceleration control
  • Challenge symmetry and provide bench marks to progress and monitor
  • 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
    Thigh motion WB thigh moves into hip adduction
    NWB thigh not held in neutral
    Knee position Patella pointing towards 2nd toe (noticeable valgus)
    Patella pointing past inside of foot (significant valgus)
    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
    Thigh motion WB thigh moves into hip adduction
    NWB thigh not held in neutral
    Knee position Patella pointing towards 2nd toe (noticeable valgus)
    Patella pointing past inside of foot (significant valgus)
    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
           
    Cross-trainer/ Treadmill/ Bike 5 Mins     90 secs
    PEP style dynamic warm up (see appendix B) 10 Mins     30 secs
    STRENGTH/PROPRIOCEPTION
           
    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
           
    Mini tramp jog 10 Mins      
    ROM (as required)
           
    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

    • Hip flexion angle at contact - hips are flexed
      Yes=0, No=1
    • Trunk flexion angle at contact - trunk in front of hips 

    Yes=0, No=1

    • Knee flexion angle at contact - greater than 30 degrees
      Yes=0, No=1
    • Ankle plantar flexion angle at contact - toe to heel
      Yes=0, No=1
    • Hip flexion at max knee flexion angle - greater than at contact 
      Yes=0, No=1
    • Trunk flexion at max knee flexion - trunk in front of the hips
      Yes=0, No=1
    • Knee flexion displacement - greater than 30 degrees
      Yes=0, No=1
    • Sagittal plane joint displacement 
      Large motion (soft)=0, Average=1, Small motion(loud/stiff)=2

     

    Coronal (Frontal) View

    • Lateral (side) trunk flexion at contact - trunk is flexed 
      Yes=0, No=1
    • Knee valgus angle at contact - knees over the midfoot 
      Yes=0, No=1
    • Knee valgus displacement - knees inside of large toe 
      Yes=1, No=0
    • Foot position at contact - toes pointing out greater than 30 degrees
      Yes=1, No=0
    • Foot position at contact - toes pointing out less than 30 degrees 
      Yes=1, No=0
    • Stance width at contact - less than shoulder width
      Yes=1, No=0
    • Stance width at contact - greater than shoulder width
      Yes=1, No=0
    • Initial foot contact - symmetric 
      Yes=0, No=1

    Overall impression
    Excellent=0, Average=1, Poor=2

    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