Recently, I had the opportunity to present to a local soccer club and their coaches on injury risk and reduction for the sport of soccer. In order to understand this, a “Needs Analysis” must be done. A Needs Analysis is a two-part analysis breaking down the sport into two components:​

• Evaluation of the Sport
• Assessment of the Individual

Today, our primary focus will be on evaluating the sport itself. This can be further broken down into:

• Movement/Biomechanical Analysis – body and limb movement patterns and muscular involvement
• Physiological Analysis – required physiological characteristics such as strength, power, endurance, speed agility, etc.
• Injury Analysis – common sites for joint and muscle injury and causative factors

Movement & Physiological Analysis

Soccer is a very lower-body dominant sport involving the hip, knee and ankle joints and muscle groups including the quadriceps, glutes, hamstrings and calves. A soccer athlete must be able to run, jump, accelerate, decelerate, land, cut, kick, pass, head, shuffle, tackle – all while handling a ball and avoiding defenders. Oh, they also need the ability to sprint and jog throughout the duration of a 90+ minute game. Now, you’re talking about a dynamic athlete with a sound aerobic and anaerobic energy system. That’s A LOT.

Injury Analysis
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Sports injuries are inevitable. It comes with playing sports – exposure already puts you more at risk. You cannot prevent sports injuries, but you can help mitigate and reduce the risk of them happening – especially ones that are non-contact or overuse in nature.​

Here’s a breakdown of the most common injuries in soccer:

Muscle strain, ligament sprain and concussions are highest as expected.

What’s most interesting is the girls’ ligament sprain – very high for both practice and competition as compared to the boys’ group. Females are 2-5 times more likely to tear their ACL than males in a similar sport. There are a lot of factors that play into this and nothing is definitive. We do know that strength and neuromuscular control are big modifiable factors from an injury risk standpoint.​

In another study from 2015, Waldén and company analyzed 39 videos for movements related to non-contact ACL injuries in professional soccer players. They found that pressing, kicking, and heading were the 3 most common movements in relation to ACL injuries.

Ask questions​

Many postpartum women do not know all of the details after birthing their baby.  Some have told me they were not aware they had stitches down below until the 6-week check-up when the doctor wanted to make sure they were healing well!  The check-up at 6 weeks can be quick so arrive with questions. It is helpful to know about any tearing, episiotomies, tools used during the birth, etc.  These factors are all great to bear in mind as you return to exercise and daily functioning.

Another question to ask-- “Is there a pelvic health PT that you would recommend?”  They may know someone in the area or have worked with them prior.  However, do not become discouraged if they don’t have a name to offer.  A Google search for “women’s health PT” or “pelvic PT” should show professionals in the area.  Compare websites and reviews to see if the PT would be a good fit for you and your goals!​


​Pelvic Health Physical Therapy

Once you have been cleared by the doctor for “usual exercise” and intercourse, I highly suggest visiting a pelvic health or women’s health PT.  They will be able to further answer any questions about symptoms you may experience immediately postpartum and later.

A pelvic PT is specialized on evaluation and treatment of the pelvic floor musculature.  They can perform internal evaluations to test the strength and endurance of your pelvic floor, check for prolapse, address any soft tissue issues, etc.

For the evaluation, the therapist will use a gloved finger to palpate muscles internally. While a great deal of information can be gathered from an internal evaluation, it is not necessary for visiting a pelvic PT.   The therapist can then prescribe exercises to help relieve the symptoms and provide hands-on work to hips, back, sacrum and other involved areas. Your PT should be a huge help in getting you back to fitness postpartum!  Other areas they can treat and improve are bowel/bladder issues, painful sex, and pelvic pain.


Focus on healing and strength rather than weight loss

Social media and advertising may be all about “getting your body back” and fixing “mummy tummy,” but that is not the focus when you are postpartum.  The first step in returning to fitness is addressing foundational strength and continuing to heal from the pregnancy and birth.  Your body will go through so many changes in the months following your pregnancy and the timeline is different for every single woman.

Steer clear of programs that say at week 8 you do blank. It should all be self-paced and based on symptoms, your birth story, and prior activity level.  Do you need help starting out?  This was the number one question I received from women in the clinic.  “What can I do?  Where do I start?” So I developed programming to recover and rebuild your core after having a baby. Check out the THRIVE: Rebuild Bundle programming HERE.

​This is where education and setting the expectations is huge. When working with an athlete, it’s important to consider this as a part of rehab. Who wouldn’t have anxiety or emotions when they can no longer play their sport and get their knee operated on. It’s completely normal. Rather than hiding it, have a conversation with your athlete. Educate them on what to expect before, during and after the procedure and for rehab. Assure them that everything will be okay and that they will get back to their sport. When an athlete knows what to expect, there’s less psychological distress associated with the process, which can significantly impact the success of the rehab and return-to-play process.
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​2. Self-Efficacy:

• Definition: belief in one’s ability to succeed in a particular situation or execute actions.

In addition to the 4 areas above, an objective measure can be very beneficial to quantify where the athlete stands from not only a physical perspective, but psychological. That’s where the ACL-Return to Sport after Injury scale (ACL-RSI) can be helpful. The ACL-RSI is a great outcome measures to assess athletes' emotions, confidence in performance, and risk appraisal in relation to return to sport.

Recognizing positive and negative psychological responses to injury is the first step in initiating treatment and potentially modifying beliefs through psychological interventions. It is important to identify patients who are at risk for poor outcomes because targeted psychological interventions may be successful. If you know of an athlete going through this injury and recovery process, don’t forget that there’s more to it than just what you can see.

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Cheers,

Dr. Ravi, DPT


Sources:
- Christino MA, Fantry AJ, Vopat BG. Psychological Aspects of Recovery Following Anterior Cruciate Ligament Reconstruction. J Am Acad Orthop Surg. 2015;23(8):501-9.
- Sadeqi M, Klouche S, Bohu Y, Herman S, Lefevre N, Gerometta A. Progression of the Psychological ACL-RSI Score and Return to Sport After Anterior Cruciate Ligament Reconstruction: A Prospective 2-Year Follow-up Study From the French Prospective Anterior Cruciate Ligament Reconstruction Cohort Study (FAST). Orthop J Sports Med. 2018;6(12):2325967118812819.
- Ardern CL. Anterior Cruciate Ligament Reconstruction-Not Exactly a One-Way Ticket Back to the Preinjury Level: A Review of Contextual Factors Affecting Return to Sport After Surgery. Sports Health. 2015;7(3):224-30.
-Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: Evaluation and treatment. Sports Med Arthrosc 2011;19(1):34-43. Melissa A. Christino, MD, et al

This means that we need to get away from time- and isolated-based assessments and look at this from a holistic 360 degree view, taking into account not only the biological factors of the athlete, but psychosocial factors as well. Since there are many individuals involved in this process, it takes a team to make the outcome truly successful. This team consists of the individual, their family, physical therapist, athletic trainer, orthopedic surgeon, sport coach, strength coach, etc.

Remember – A single component alone (i.e. time) is not enough to determine whether someone is ready. All of the components below could have the box checked except the last one and this athlete would still not be ready. I hope this provides some insight to you if you are going through this process as an athlete, parent, or clinician looking to return to sport. ​

1. Time: > 9 months after ACLR.
2. Patient-Reported Outcome Measures:  IKDC2000, Tegner Activity Scale, ACL-RSI, K-SES.
3. Clinical Exam: Full range of motion, no pain, swelling, or laxity.
4. Muscle Strength: Pivoting, contact, competitive sports (>100% limb symmetry index); non-pivoting, non-contact, recreational sports (>90% limb symmetry index).
5. Hop Tests: Multi-directional (90% limb symmetry index).
6. Assessment of Movement Quality: Multi-segment movement quality with and without fatigue
7. Task and Environmental Constraints: Gradual progression of controlled tasks and environments to progressive, uncontrolled tasks and environments to replicate sport.
8. Medical and Sport Risk Modifiers: Age, sex, personal medical history, type of sport, level of sport, position played, ability to protect (e.g. taping/bracing).
9. Decision Modifiers: Timing of the season, external pressure from club, trainers, parents, conflict of interest (e.g. financial), lifestyle changes, priorities.
10. Psychological Factors: This one is commonly overlooked – that is why next week, we will dive deeper into psychological readiness and how we can make sure this becomes just as important as the physical component of ACL rehab and performance.

Cheers,
Dr. Ravi


Source: Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sports Med. 2017;47(8):1487-1500.