Psychological Measures for Return to Play Following ACLR, Part 3

Psychological Measures for Return to Play Following ACLR, Part 3

In this series we’ve been talking about kinesiophobia (fear of movement) and specifically how this is related to an increase in re-injury risk with athletes returning to play. In the last post, we provided a case study with an athlete who was being assessed for return to sport-specific testing.

19 y/o female division I soccer player who is 5 months post op R ACLR. She has been receiving “accelerated” rehab in an aggressive sport-specific training center in Florida. She’s being assessed for return to sport-specific training. We are engaged by the team to do our movement assessments, which is an aggressive movement assessment (ViPerform AMI) using 3D wearable sensors. This test consists of:

  1. 1-minute Plank test
  2. Squat test
  3. 1-minute side plank (right, then left)
  4. Single Limb tests (all on right first, then the left)
    1. Single leg squat
    2. Single leg hop
    3. Single leg hop plant (multidirectional hop)
    4. Ankle lunge test

At the 5-month mark, most s/p ACLR should be able to perform the test. Part of the pre-requisites for the test is that the athlete must have performed each of the movements safely in the clinic prior to testing. When asked to do a single-leg squat, you could visibly see the athlete was hesitant to perform, but she did, and did so safely. When asked to perform a single-leg hop, the athlete’s hesitancy increased: she started sweating profusely and began to feel light-headed. This is an extreme case of kinesiophobia! But why did she have this kind of response?

This could have been avoided if several things had been done prior to the test.

  1. Inform the athlete what the test will consist of prior to them arriving. This athlete was unaware of what the test consisted of, so the first time she was hearing about it was the moment she was asked to do it.
  2. Have the athlete safely demonstrate movements in a controlled environment prior to testing. This is critical to see if the athlete is even at the point where testing is appropriate.

As simple as that sounds, neither of these were done in this case. More importantly, the athlete had only begun to do single limb training a week prior to testing, and had never done single leg hops at all. So, in the athlete’s mind, this was not only the first time they had done this but also was similar to the mechanism by which they injured their knee initially. No wonder she was having an extreme case of kinesiophobia. She was set up for failure.

Trends we have been seeing for the last several years in athletes with high levels of kinesiophobia are:

  1. The athlete tends to have a large lateral shift with bilateral squats where they are unloading the post-operative side.
  2. The athlete has difficulty controlling how much their knee moves in the frontal plane during single limb testing.
  3. The athlete has difficulty controlling the speed at which their knee moves in the frontal plane during single limb testing.

The first of our findings were confirmed recently in a study by Noehren et al Am J Sports Med 2018. In this study the authors had athletes who were post op ACLR do a Tampa Scale for Kinesiophobia (TSK) and perform a drop jump from a 12 inch (30.48 cm) box onto a force plate. What the authors found was that athletes who reported high levels of kinesiophobia on the TSK also unloaded their involved side during a drop jump test. This is very similar to what we have been seeing with a lateral shift. Athletes with higher levels of kinesiophobia demonstrate a shift away from the involved limb. The problem with this is we would see this also carried over into their training. So the athlete that demonstrates this in a body weight squat would also demonstrate this, sometimes even exaggerated, during a squatting motion under load. So is it the kinesiophobia that leads to the shift or the shift that leads to the kinesiophobia? Although we don’t know this answer, we do know we can positively impact both.

The other trend we tend to see is the athlete having difficulty controlling the amount and speed of frontal plane motion. This hasn’t been proven in the research yet, but it is something that we see quite often. This is also something that we are currently researching in our work in assessing athletes for return to play. That being said, what we see is that athletes who have high levels of kinesiophobia have greater degrees of valgus during single leg squats, single leg hops and single leg hop plants. What we also see is that these same athletes have higher speeds at which they fall into a valgus position during single limb testing.

Taking the athlete pictured below, he reports a higher level of kinesiophobia and falls into valgus at >40  degrees per second in a single leg squat, >180 degrees per second in a single leg hop and >220 degrees per second in a single leg hop plant. Considering these speeds should be 20 degrees sec in single leg squat, 100 degrees per second in single leg hop and 135 degrees per second in single leg hop plant, the athlete demonstrates speeds that are way outside the norms of what we typically see.

This is great information to have but how do we change it? Next time we will dive into how we can train an athlete to reduce a lateral shift, amount of valgus in single-limb activities and speed and positively impact kinesiophobia.


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