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• Movement is pain – free

• Full ROM: Elasticity is restored

• Balance: Athlete is able to balance (apply pressure to) on their injured limb 

• Strength: The new tissue is able to support the body in stressful movements

• Full mobility

 

Physical tests provide a point of comparison and practicing game situations can determine fitness as well as the level of pain and mobility experienced by the athlete. 

 

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• Testing range of motion

• Normal strength on muscle testing

• Symmetrical squat and lunge movements

• Single leg squats for knee injuries, within normal limits compared to uninjured side

• Physical fitness tests (beep test for endurance, Illinois shuttle run for agility, sit and reach test for flexibility etc.)

• Normal running gait without pain or instability

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6m timed hop test

Starting at a certain point, the athlete will balance on one leg and hop as fast as they can over a distance of 6 metres. In order to pass, the injured leg must hop 6 metres in at least 90% of the time in comparison to the uninjured leg.

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Single leg triple hop

Starting at a certain point, the athlete will balance on the uninjured leg and hop forward three times consecutively, as far forward as possible. The athlete must maintain their balance to the last hop to pass the test.

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Single leg broad jump

Starting on the designated line, the athlete will jump using both legs as far forward as possible, landing on one foot, maintaining balance.

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Readiness for return to play is comprised of more than just the athlete’s physical capabilities. Psychological readiness is demonstrated by a positive outlook and confidence. A balance between a desire to return and common sense is essential to avoid re – injury and damage to confidence. Taping is a strategy to assist confidence and cognitive tests may also be used to indicate readiness. Counselling is recommended after a serious injury and returning to play at a lower level initially can be highly beneficial.

 

 

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 The warm - up needs to be more specific to the injured area when returning from an injury. For example, an athlete with a previous knee injury would need some extra low – impact activities, stretching and agility exercises to the leg muscles to ensure that these have been worked in a safe environment beyond what will be demanded of them in competition.

 

Examples may include a slow slalom jog, balance on one foot, hopping, agility ladder or taping of the joint.

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These warm - up exercises are predominantly targeted at the correct alignment of the knees and feet whilst jumping. These exercises are specifically targeted at the development of muscle memory post - ACL reconstruction. They are also tailored the requirements of a basketball game - jumping to throw and catch  (as demonstrated in the management section).

 

Squat jumps: This exercise engages multiple muscle groups in the lower body whilst ensuring the correct technique while jumping and landing. The proper positioning of the feet, knees and hips are vital to the maintenance of correct technique. ACL injuries can be caused by the misalignment of the knees when jumping, especially in sports such as basketball. Therefore the rigorous practice and training of correct technique is vital to avoid the instance of re - injury.

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Walking forward lunge: This exercise works to achieve similar outcomes to the squat jump.

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Jump lunges: This exercise encompasses the principles of squat jumps and walking forward lunges. 

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Single leg lateral hops with agility ladder: Knee position is key when jumping side to side. When pushing off and landing, proper positioning should be maintained, ensuring the knee is pointed straight forward. The body weight should be centred over the leg upon landing.

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Running butt kicks: This dynamic warm - up exercise is targeted at increasing the heart rate and loosening the muscles in preparation for physical activity and competitive sport.

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Lateral shuffles: This dynamic warm - up exercise is targeted at increasing the heart rate and loosening the muscles in preparation for physical activity and competitive sport.

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• Administrators, sports med practitioners and coaches have a vital role in establishing and enforcing guidelines.

• Return to play policies and procedures vary with every sport as well as the nature and severity of the injury. E.g. A concussion in basketball can vary significantly from a concussion in football.

• Some require medical certificates, and some require you to pass certain tests.

• Sometimes it is a requirement to tape for isolation.

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Guidelines for ACL injuries state that the athlete should not return to play for 4-8 weeks once full ROM is restored and joint swelling has completely subsided. In order to return to competitive sport, the athlete is required to complete/pass the following tests: 

• Physician approval

• Lower extremity functional test

• Functional Hop test

• Functional jump test

• OKC Isokinetic test

• Kinaesthetic/proprioception testing

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Based on present literature and clinical experiences, it is therefore recommended:

• A plethora of varying tests are completed, examining strength and power​

• Examination via proactive and reactive activity to stimulate a real - case sport scenario

• Psychological testing to evaluate for potential kinesiophobia

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Pressure to participate – How important is the competition? Is there pressure from sponsors, coaches, family or self (financial)?

External pressure - Coaches may view their players as a commodity and seek to get from the athlete what its costs to be a part of the club. For example, a basketball player returning from an ACL injury may be considered one of the most valuable players on that particular team as they usually play a significant role in their team's victories. This places pressure on the athlete from not only their coach but other team members and sport spectators to return to play before they are physically and mentally prepared to do so.

Internal pressure - The most dangerous pressure is said to come from the athlete themselves. Professional athletes are often highly motivated and driven to succeed. They may feel a fear of missing out, fear falling behind on their personal goals or they may fear letting their team, coaches or family down. This may compel athletes to lie to doctors and physios about symptoms they are experiencing in order to return to their sport faster. For example, a basketball player returning from an ACL injury may tell their physio they no longer feel pain at the knee joint when completing basketball drills and range of motion exercises. They may also assure them they feel confident and determined to return to the court. 

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It is unethical for any coach or staff member to pressure an injured athlete to return to play faster than what is necessary. It will lead to greater injury and possibly even hinder the potential of the athlete further down their sporting career. 

 

Use of painkillers – Although this is an attractive option to speed up return, players should not make the decision to use painkillers unless instructed by a medical professional or team doctor. Pain exists to alert the athlete when a particular movement may cause damage to the body. By eliminating the presence of this sensation, greater injury may occur because the body will not be able to identify when a particular movement is causing further stress and trauma to a joint.

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There are also considerations as to what drugs may be used and their concentration. It may be ethical for an athlete to use Panadol or Nurofen as they are a weak painkiller, but it may not be appropriate to use stronger drugs such as codeine, methadone and morphine.

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In relation to a basketball player recovering from an ACL injury, it would be highly unethical to allow the consumption of painkillers. This is due to the severity of the injury and the consequences they would be forced to deal with in the likely event that the injury inflames and worsens again. There are times when painkillers are used to relieve minor issues such as muscle spasms, which would in this case be perfectly ethical. However, the use of painkillers in scenarios such as an ACL tear, is highly unethical due to the risk it poses to the athlete. There are only small gains to be made from returning to play before being fully prepared, such as a team victory, but the long - term consequences far outweigh the need to compete at an early stage in the recovery process. Especially in team sports such as basketball, players can easily be substituted whilst the injured athlete recovers. It is much harder to resist the pressure to take painkillers and give in to other pressures when the athlete is competing in an individual sport such as gymnastics or tennis.

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