ACL Return to Sport: Where are we and what are you MISSING!

​Did the title of this post catch your eye? Articles with similar titles have caught my eye for years in my quest to understand proper sports rehabilitation and return to sport. Yet, despite completing a sports physical therapy residency with USC in 2014 and becoming a board certified sports physical therapist, I still find myself searching for more answers every day. I end up with more questions most of the time (which I think means I’m on the right track?).  
 
Regardless of my current quest to continue to improve my knowledge and ultimately application of knowledge in return to sport, there are a few things I have learned that are worth sharing.  Return to sport is a big buzz word and I feel confident saying that not one person has all the answers.  I’ve been lucky to be in a residency class that boasts two NFL physical therapists (Rams & Eagles) and every conversation I’ve had with them (in the past and recently) demonstrates to me that they too are constantly searching for ways to improve these processes.  Which is pretty crazy because they have great track records.  
 
My interest in ACL return to sport stems from my love for basketball and my years of special interest in treating the basketball athlete.  Unfortunately, too many basketball players suffer from ACL injuries. This sparked my interest in understanding why this happens, how we can better prepare these athletes (prevention), and what we can do to successfully return them to sport at the highest level. I say return to sport at the highest level because too often I see players return to practice level but not full game level.  
 
Currently, literature has focused on more objective criteria and milestones based progressions. However, as we know, it does take the literature time to catch up to what we see anecdotally.  Functional tests are good but do not take into consideration reactive measures.  I find myself using these tests but often adding in different movement testing with reactive components to try to mimic sports.  After all, almost all movements in sports are unplanned.  Training our athletes during their rehab or injury prevention in reactive environments can be very useful. 
 
How can we start to train “reactive” components?  I find it best not to overthink this and I often use auditory commands or visual commands. For example, when training a basketball player with shuffling in a defensive stance, I will say “Right!” or “Backwards!” or “Left!” continuously for a specified time to signal to the player to shuffle in that particular direction. Using your hands to point in specific directions is another way to do it by challenging a different sensory input. Lastly, using props such as a foam roller, tennis ball, basketball, etc to throw or drop it in a particular direction can be very effective in training reactive first steps.  It’s important to note that I often like to record these drills to look at movement both in the moment and afterwards to see what I missed with their preferred movement strategies.  
 
ACL return to sport needs to be a multifactorial approach.  As this literature article suggests, there are many ways to start preparing our athletes for their eventual return to sport.  Understanding the particular athletes sport is something that is also absolutely crucial.  Adding psychosocial components, fatigue testing, reactive testing, and sport specific movement based testing is just as important.  If you have ACL athletes and do not understand the biomechanics of their sport, take a look through the literature and check out our resources here and here.  Most importantly, continue to ask questions to yourself with each athlete you have to find continued ways to improve their outcomes. 
 
Dr. Brian Schwabe, PT, DPT, SCS, COMT, CSCS 
Board Certified Sports Physical Therapist 

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