Usually 16 weeks post-op is when I would begin to work with the athlete. This is usually when physical therapy has exhausted its return on investment with the athlete, and now it is time to begin a strength training program. But before we talk about the training program, I am going to be discussing a two-pronged evaluation system: Level 1 and Level 2.
Level 1 assessment aims to evaluate the athlete’s functional abilities such as balance, symmetry, and also identify any issues such as valgus, noticeable poor gait patterns, hip drop, and (in)sufficient knee flexion. If at any point during the assessment the athlete feels pain, cease the activity and move on. If the athlete feels pain on the next series of assessments, cease the assessment process as a whole and direct them back to their surgeon. Pain is not ok, discomfort is, as long as it is tolerable.
The assessment’s testing order is:
· Anthropometric
· Y-Balance
· 60 second Front Step Down to 45 Degrees (6” box)
· 10 Step Up & Hold
· Single Leg Bridge – 60 seconds
· Plank – 60 seconds
· Side Plank (R/L) – 30 seconds each
· Gait Assessment
The first thing I do is take anthropometric measurements of the athlete’s thigh and lower shank of both limbs. I take anthropometric measures on day 1, week 6 and week 12.
Y-Balance
Prior to performing the Y-Balance test I measure leg length. The athlete lies supine, and I use a tape measure starting from the ASIS and measure down to bottom of the medial malleolus. The limb measurement is used to identify any length discrepancies that might have developed since the injury occurred. This happens when the body begins to compensate for lack of strength by tilting the pelvis down. The leg length number is then multiplied by the number of directions used in the test, which is 3.
Once I have the measurements, the athlete begins Y-Balance. Key thing to keep in mind, make sure the heel of the foot stays flat when performing the Y-Balance. I then add up all 3 measurements from the Y-Balance for the Right and Left leg separately, giving you a Composite Score for each leg. Divide the Composite Score from the Leg Length x 3 number and you will get a Percent Deficit. A lot of questions will be answered in this test. If the deficit is greater than 10% then the athlete is at a very high risk for re-injury. The long term goal is to try and achieve less than 4cm difference between limbs and 95-100% Composite Score % Deficit.
60 Second Front Step Down Test to 45 Degrees
In this test, we aim to look at contralateral differences in strength, endurance, posture, and knee control (valgus). The goal is have a difference of less than 10% repetitions between limbs. Why 45 degrees? Well, we are looking to identify if the VMO can “screw” the knee into its extended position. and if there is enough control in this terminal position. The athlete will begin on top of the box, tap the off-leg heel on the ground and go right back up for as many reps as possible.
10 Step-Up and Hold
This is a basic test, a regular step up with 90-degree knee flexion. The athlete will being with their hands on their hips, stand all the way up, and drive the opposite knee up to a flexed position and hold for 1-2 seconds. Here we are looking to identify single leg balance, leg strength from 90-degree knee flexion, any noticeable hip drop, excessive trunk lean (in any direction), excessive lordosis, and valgus. Also, when the athlete is performing this test on the injured limb, be aware of eccentric control.
Single Leg Bridge
Very simple assessment. We take a look at glute strength and endurance, and also if the athlete is able to produce force with the knee at a greater degree of range than the prior assessments. Here the athlete will perform as many reps as possible (in a controlled manner) for 60 seconds.
Look for:
Hip extension
Valgus
Excessive lordosis
Heel contact with the ground
Plank / Side Plank
Plank
This goes a little more beyond the typical “core strength/endurance” test. In the plank, I look to see if the athlete possesses any compensatory patterns such as hip shift,rotated hip, excessive lordosis, high hips. I place a short dowel (3-4 feet long) along the athletes spine and hip. The dowel will tell you if the hips shift and how excessive of a lorthodic curve is present. Also the dowel will constantly fall off if the hips hike up.
Side Plank
Same as the regular plank, however now we look to identify oblique and glute medius (among other muscle groups as well, however these two are most important for now) strength between limbs. What I usually find here is that most athletes do not have enough strength on the side of the injured limb to hold up without shaking, dropping/rotating hips, placing the opposite hand down for quick balance, or not achieving the same hip height as the opposite side. I usually do this near a wall to get visual reference as to the height of each side. Some noticeable things when looking at the injured limb side: Bending torso, failure to achieve full hip extension, failure to hold for duration of time.
Gait Assessment
This is where you as a coach, begin to determine what your “coaches eye” sees when the athlete walks. I begin by telling the athlete to walk 30 yards at a normal pace, and walk back towards me at a faster pace as if they’re late for class. I can tell you most of what I see, however this is where you have to be able to identify what the individual is showing you. I’ve seen hip drops, crossover steps, noticeable limp, decreased stride length on injured limb, the list goes on and on. People are different, that is why I say to you, use your coach’s eye and determine what you see in their movement.
Conclusion
So, now you’ve completed the Level 1 assessment with your athlete, what’s next? Well, determine if they passed or failed by the Y-Balance test. Every other test is a baseline measurement for now, obviously that “baseline” changes over time as we look to develop a more symmetrical body again. However key notes to identify:
1) Eccentric knee control
2) Proximal leg strength
3) Neuromuscular strength
4) Pain during assessment
If there is pain in any movement, shut down the exercise and move on. If pain is persistent throughout the test, I would highly recommend ceasing all activity and recommend the athlete to see their surgeon. If all is well, minus a bit of discomfort and fatigue (yes, they will be fatigued after doing the Level 1 assessment) prepare the athlete for Level 2 assessment within 48 hours of Level 1.
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FULL DISCLAIMER
I AM NOT A LICENSED DOCTOR, NOR PHYSICAL THERAPIST. THE INFORMATION PRESENTED IS BASED ON MY PERSONAL EXPERIENCES WORKING WITH SURGEONS AND THEIR ACL RECONSTRUCTED PATIENTS AND DATA I HAVE COLLECTED. IF THERE IS ANY PAIN DURING ANY PART OF THE ASSESSMENT, PLEASE CONSULT YOUR SURGEON IMMEDIATELY AND REPORT SYMPTOMS. DO NOT PUSH THROUGH PAIN AS THIS CAN LEAD TO FURTHER INJURY.