Leanne Simoncelli – Optimising and Individualising ACLR Rehabilitation – Injury Rehab Network Event

The first of two Injury Rehab Network events in March 2023 featured Leanne Simoncelli, a Physiotherapist working with elite athletes at the ISEH – Institute of Sport, Exercise & Health. The online event took place on the evening of 9th March, with over 220 sports rehabilitation professionals in attendance.

Leanne’s presentation drew on her experience and research to investigate using objective measures to guide return to sport rehabilitation following ACL reconstruction or surgery.

The recording of Leanne’s presentation is available to watch here

Leanne Simoncelli, Physiotherapist (Institute of Sport, Exercise & Health)

Leanne Simoncelli is currently working as a Clinical Specialist Physiotherapist at the ISEH – Institute of Sport, Exercise & Health. She qualified with an MSc in Sports Medicine and Exercise Health from UCL in 2015. Her research focused on ACLR Return to Sport Testing.

Leanne qualified as a physiotherapist from the University of Cape Town, South Africa, in 2004. She has further training in Shockwave Therapy, Acute Sports Trauma Management, Clinical Pilates, Acupuncture, Advanced Hydrotherapy (Aquatics Therapy), Spinal Manipulation, Sports Massage, Gait analysis, Cycle Ergonomics, Taping / Strapping and, most importantly, Advanced Rehabilitation and return to sports planning.

Leanne has worked with a variety of sports teams and International sporting events. Some highlights include:

• The rowing and sprint canoe events at the London 2012 Olympics at Eton Dorney
• The 2014 Commonwealth Games in Glasgow
• The 2015 European Games in Baku
• World University Games in Naples 2019 and Chinese Taipei 2017
• Physio support to the match officials at Twickenham and Milton Keynes at the 2019 Rugby World Cup
• England Academy Netball
• Netball Tour to New Zealand
• European Trophy Championships for Ladies Hockey
• British University & College Sports
• Multiple London Marathons
• London Ride100
• Rowing training camps in Portugal
• Sark Island Adventures with NIKE athletes
• Multiple UK School Games
• Hampstead and Westminster Hockey
• Barnes Rugby.

Leanne also worked at Stratton Ski Resort in Vermont, USA, for two seasons.

Optimising and individualising ACLR Rehabilitation

Leanne’s presentation, “Optimising and individualising ACLR Rehabilitation”, investigated how using objective measures as well as age, gender and sport-specific normative data can best guide the tailored-made progressive return to sport rehabilitation following ACL reconstruction or injury.

There is hope!

Leanne commenced her presentation with examples of professional athletes who have come through ACL reconstruction rehabilitation and gone on to be successful at the highest level. Athletes include Megan Rapinoe (World Cup winner), Lyndsey Vonn (Olympic gold and bronze medalist), Tom Brady (7 x Superbowls) and Zlatan Ibrahimovic (Professional Footballer at AC Milan). These athletes show there is hope for those who suffer ACL injuries and have reconstruction surgery.

Leanne described how physios and those working in sports rehabilitation could and should use the evidence and resources available to them to enable athletes to return to sports.

Framework for Return to Sport Following Anterior Cruciate Ligament Reconstruction

Leanne presented the outline framework for return to sport following ACL reconstruction, which focuses on the following areas:

• Individual
• Rehabilitation progress
  • Full range of knee flexion and extension
  • Muscle strength/ capacity
  • Neuromotor control/ balance/ coordination
  • Perturbation training
  • Reactive agility
  • Contact and impact
• Return to sport

Research

Leanne utilises and recommends the following research papers to support effective ACLR rehabilitation:

• Return to sports after ACL injury 5 years from now: 10 things we must do
• Recommendations for Hamstring Function Recovery After ACL Reconstruction
• Optimising the Late-Stage Rehabilitation and Return-to-Sport Training and Testing Process After ACL Reconstruction
• Optimising the ‘Mid-Stage’ Training and Testing Process After ACL Reconstruction
• Rehabilitation and Return to Sport Testing After Anterior Cruciate Ligament Reconstruction: Where Are We in 2022?
• Unique Considerations for the Pediatric Athlete During Rehabilitation and Return to Sport After Anterior Cruciate Ligament Reconstruction
• Rehabilitation Using a Systematic and Holistic Approach for the Injured Athlete Returning to Sport
• Age-, Sex-, and Graft-specific Reference Values From 783 Adolescent Patients At 5-7 months After ACL Reconstruction: IKDC, PEDI-IKDC, KOOS, ACL-RSI, Single-leg Hop, and Thigh Strength
• Periodization in Anterior Cruciate Ligament Rehabilitation: A Novel Framework
• ACL Rehabilitation: How Can We Lessen Injury Rates?

Focus on the Individual

Leanne discussed the importance of understanding the individual and developing a personalised approach to rehabilitation. Practitioners should consider past medical history, other injuries and the athlete’s mindset. Leanne described four key areas to consider in relation to each individual patient:

1. Age – considerations include adolescent (skeletal maturity?), adult, and post-menopausal.
2. Gender – Male/ female, transgender, binary (hormonal profile), access to training (equal based on gender?).
3. Site and type of graft – hamstring, bone patella bone, allograph, family donor.
4. Sport and position – specific demands and requirements of the sport and position played.

Leanne discussed motivation and the factors that may impact on an athlete’s motivation to work hard on their rehab.

• Motivation – Career/ finances, competition, selection cycle, intrinsic/ extrinsic
• Learning style – visual, auditory, tactile
• Resources – Financial, time, gym, strength and conditioning access, coaching, nutrition
• Performance pathway – where in the journey?

Rehabilitation Progress

Leanne introduced a continuum for rehabilitation progress transitioning from the pre-operative stage to early-stage rehab, mid-stage rehab, late-stage rehab and finally, the return to sports stage.

Full range of knee flexion and extension

She described the criteria to progress from early to mid-stage rehabilitation with a range of outcome measures, tests and targets assessing:

• Pain
• Joint effusion
• From knee extension
• From knee flexion
• Quads activation
• Gait

Leanne discussed the importance of a cool and calm knee and how early knee extension is key for a smooth, balanced gait.

Muscle strength/ capacity

She discussed the muscles that should be focused on for ACLR rehabilitation, including quads, glutes, hip rotators (internal and external), hamstrings, gastroc, trunk, soleus, hip adductors (short and long) and hip abductors. For exercise selection, Leanne described how variety is key, with clear criteria for progression and measures to test strength.

Leanne considered a range of areas for exercise selection, including:

• Hip and knee based
• Closed and open chain
• Inner, middle, and outer ranges
• Short and long lever
• Slow and fast contraction
• Body weight and loaded
• Double and single leg
• Plyometrics
• CV fitness (including running)

She considered the importance of quadriceps strength, and strength symmetry over stages of rehabilitation and the importance of understanding normative strength values. Leanne uses a handheld dynamometer, force decks and force frame to measure strength with assessments for knee extension force max, knee extension rate of force development and global hip force production.

She described how colleagues at ISEH have developed an excel tool which cleverly rates strength against expected values for a range of exercises/ tests/ movements.

Criteria to progress from mid to late rehabilitation

She discussed how isokinetic tests are used to assess quads and hamstrings capacity with a symmetry ratio used to assess strength and progress through rehabilitation. Closed chain efforts include tests with leg presses and single-leg isometric squats. Glutes capacity is tested with a single leg bridge, and calf capacity is tested with heel raises for gastroc and isometric peak force for soleus.

Leanne described how static balance is assessed with a single-leg stance, and movement quality is assessed through a single-leg squat to 60 degrees. She showed how running gait is assessed with video analysis using a 10-minute treadmill test.

Neuromotor control

Leanne discussed how she encourages athletes to think of themselves as a supercar with speed and power. However, this power requires agility and control, and this is where neuromotor control is particularly important in rehabilitation.

Leanne described how rehabilitation at this stage focuses on the following:

• Movement quality
• Landing strategies
• Change of direction
• Cutting, pivoting
• Acceleration
• Deceleration
• Time to stabilisation
• Dynamic balance

Braking, propulsive and landing forces are assessed with the aim of getting equal and symmetrical results for both sides. Leanne discussed how a drop jump is an important test at this stage.

Perturbation training

She described how perturbation training focuses on control of the body in the air and the ability to absorb force. At this stage, rehab may focus on introducing the athlete to various in air conditions, including:

• Bump
• Push
• Contact
• Call
• Distraction
• Throwing
• Catching
• Header

Reactive agility

Leanne discussed how reactive agility focuses on developing uncontrolled and uncertain training through a range of auditory and visual methods.

Auditory training includes the use of a sound (whistle/ bell/ buzzer/ beep) to prompt movements in different directions. Specific words or instructions may also be given.

Visual training includes a visual cue (person moving, lights, colour of object, ball drop/ kick/ throw, flag) to prompt different movements or exercises.

Contact and impact absorption

Leanne described how these activities might include the use of kick pads, tackle bags and other equipment.

Return to Sport

She discussed the Return to Sports Continuum from the 2016 Consensus Statement on Return to Sport from the First World Congress in Sports Physical Therapy, Bern. The continuum includes stages for injury, return to participation, return to sport and finally, return to competition.

Leanne described how the return to sports stage should be based on the field of play and with the performance team (coaches, strength and conditioning etc.). The aim is for athletes to progress from linear/ controlled exercises, without restrictions and through to competition. Leanne presented a range of stages and exercises for return to sport progression, including:

1. Pre-planned linear
2. Pre-planned multi-directional and rotation
3. Dual-task reaction
4. Sports-specific drills with equipment
5. Team training sessions – no contact/ impact
6. Training sessions without restrictions
7. Competitive matches

She explained that athletes should have a phased return to competitive matches and may initially play in a friendly before playing part of a game as a sub. Finally, athletes may participate in a quarter or second half of a match.

Take Home Messages

Leanne concluded her presentation with the following take-home messages for practitioners:

1. Personalised criterion based on progressive rehabilitation
2. Recognise psychological, social, and contextual factors
3. Use normative strength and power data – consider age, gender, sport (+ position)
4. Objective testing throughout the process to target exercise prescription
5. Sensory and cognitive rich rehabilitation environment
6. Return to the sport continuum in the field of play environment

She reflected on the world-class athletes who are proof and provide hope that rehabilitation from ACL reconstruction and a successful sporting career is possible.

Leanne’s final advice for practitioners is to aim to get athletes back to the sport, stronger and more robust than before the injury.

Q&A

She kindly answered questions put forward by the practitioners who attended the session.

Q1. What are the outcomes post-op for autograft when using patella tendon vs hamstring?
A1. With patella and quads grafts, there is often anterior knee pain, and longer duration of joint effusion. It’s also more difficult to maximise the strength of the quads and slower to regain an active straight leg raise.

Q2. Are there any recommendations for loading pre-ACL reconstruction operation?
A2. Consider baseline strength for key lower limb muscles. Work on single-leg eccentric exercises. Ensure the knee is calm and cool prior to surgery, so advise not to work too hard prior to surgery.

Q3. What recommendations do you have for pool work?
A3. Pool work is used in pre-op and early-stage rehabilitation to overcome land-based forces.

Q4. Is a return to sport the same for adolescents?
A4. The return to sport timeline for adolescents is two years. Remember, the athlete has also suffered two fractures and the importance of protecting growth plates. Advise focusing on outcomes/ criteria rather than time.

Q5. Is a patella or hamstring graft better for rehab, and what are the timeframes?
A5. Hamstring grafts are usually more successful with less anterior knee pain. Rehab should aim to optimise the quad muscle. Timelines should be used as a guide, not dictate.

Q6. Which guidelines would you recommend following for ACLR rehab?
A6. See above/ presentation for recommended research papers.

Q7. Is it advisable/ possible for an athlete to do a single leg squat with weights at six months post ACLR surgery?
A7. It’s ok to use weights at this stage of rehab, and it really depends on strength. The aim is to improve strength, so the use of weights is good. The force platform can be used to assess how much they are loading and unloading. The amount of weight is a question for the S&C coach. Advise assessing capability and motor control before progressing/ increasing weights.

Q8. How should you prioritise/ structure rehab activity and exercises throughout a week?
A8. Rehab work is usually structured with 2 x strength training sessions per week (48 hours between sessions), and 1 x plyometric training. At least 4 training sessions max effort (with additional cardio and upper limb). Aim for 2 x rest days. Rehab is periodised, including rest blocks.

Q9. What are your thoughts on single-leg drop jumps as return-to-play tests?
A9. Way better than hop for distance or triple hop as it includes landing absorption and can assess with force decks. Can progress to drop jump with vertical jump and also add in a task.

Q10. Is it advisable to build knee strength as much as possible?
A10. Yes – aim to get stronger than before. Use normative data to assess what is strong for each individual athlete.

Q11. Do younger athletes have poorer outcomes due to bones still not being fully grown?
A11. Older athletes may have less time in their competitive sports environment, whereas younger athletes have a lot more time. Depending on skeletal maturity, growth plates may not have fused. Testosterone levels may be lower. The development of the brain may also affect rehabilitation, as decision-making may not be as effective prior to the prefrontal cortex being developed.

Q12. How do you assess skeletal maturity?
A12. This isn’t done by the physio team but is determined by doctors who use x-rays or CT/ MRI scans to assess how close growth plates are to fusing.

Q13. Is crepitus without pain ok?
A13. Yes – a painless noisy knee is not a concern.

Q14. If you do not have access to a handheld dynamometer, would you recommend testing with a single-leg extension?
A14. This can be done but doesn’t provide the same quality of data to help target rehab. Muscle capacity tests are great, but it’s best to get as much objective data as possible. Testing could be outsourced if you don’t have access to equipment.

Q15. Is it realistic for an athlete to return to competitive rugby following ACL reconstruction?
A15. It is possible, but it depends on the type/ level of rugby being played and the motivation of the athlete. A lot of hard work is required. Consider strength criteria and put in place a solid rehabilitation plan.

Q16. When is proprioception introduced?
A16. Ties in with the neuromotor control aspect and balance. Aim to go more in-depth than just proprioception. It can be part of the pre-op exercise but I don’t want to risk any worsening of the injury.

Q17. Do you have any experience with non-operative ACL rehabilitation?
A17. If the knee is stable and a surgeon deems it safe, then it may be possible for an athlete to continue to participate and even compete without surgery. It can work for some athletes where muscle strength is extremely high. Some older/ non-professional athletes may also be able to manage without surgery, particularly for linear sports (without twisting/ turning). An athlete who can manage without their ACL are known as ‘copers’.

Q18. Can athletes get their stitches wet after surgery?
A18. Recommend that you don’t get stitches wet as the skin hasn’t sealed. Don’t risk infection inside the knee surgery. Can use waterproof dressings but try not to get wet or even use cream around the area.

Presentation Recording

The recording of Leanne’s presentation is available to watch here

Follow Leanne Simoncelli

• Twitter @PhysioSIMONCEL1
• ISEH website

2023 Injury Rehab Network events

Find out about and register your interest for all the Injury Rehab Network events with BASRaT planned for 2023

Please enter your details into the form below along with any questions or comments and a member of our team will be happy to provide you with more information: