End Stage Knee Rehabilitation

Working with rugby union players, I see many acute traumatic knee injuries. Recently, a player presented with ongoing knee "niggles" since returning to rugby.

The player underwent an ACL reconstruction on his left knee in 2014, then injured his right MCL and meniscus in 2016. On returning to rugby in 2017, he experienced bilateral patellofemoral pain, intermittent tibiofemoral pain and recurrent apprehension when twisting on his reconstructed knee.

He received a contract to play professional rugby so was keen to address his biomechanical deficits and retrain his single limb control, to improve his performance and prevent a recurrence of knee injuries, prior to beginning a professional pre-season.

A previous blog explains the initial rehabilitation plan for an MCL injury. You'll find that here.

However, gaining good static control and good quads/gluteal/calf strength is not enough to return this athlete to high speed, quick change of direction sport. So we had to incorporate instability, ball handling, cutting and landing movements into his exercises, ensuring excellent control and technique, to return him to rugby symptom-free. 

Some examples are below, however these are just a small taste of the exercises he completed. They are to inspire you to think outside the square, to challenge your patients and ensure they have excellent control while completing their agility exercises.

1. Single Leg Balance on Unstable Surface with External Perturbation (Throwing the Ball)

The player has to balance on one leg on an unstable surface. This increases the activation of the deep hip rotators, with gluteus maximus, quadriceps and ankle stabilisers. The player has to maintain a neutral knee position (not letting their knee roll inwards into a valgus position). They then have to focus on an external object and catch then release the ball maintaining their "good" leg position. It's very challenging to counteract the force of the ball then produce the force to throw without falling over!

2. Sideways Throw on Unstable Surface

Again, the player has to maintain lower limb stability on an uneven surface, however now has to further stabilise through the gluteals and abdominals to counterbalance the arms rotating across the body. It's a crucial movement in rugby, as the player only passes across the body. There is high risk of the knee rolling in while passing, so retraining this movement is essential. The instability of the trampoline adds difficulty. 

3. Cutting Movements To Receive a Pass

A backline player has to routinely cut (change direction at a 45-90 degree angle) to get past the defence. It is the most common mechanism of ACL injury. Effectively retraining this movement drastically reduces the risk of recurrence of ACL re-injury. The player must plant with their toes pointing forwards, if they plant their toes pointing outwards, they require greater internal rotation at the hip and knee to change direction and have greater risk of re-injuring the ACL. If their foot faces forwards it's a smaller angle, so less risk of excessive internal rotation at the femur on the tibia. Retraining this foot planting position is crucial! 

4. Landing Drills

A player must land with knees pointing forwards, with minimal knee valgus (knees rolling in). While we teach squats and lunges with good knee position, we must progress this to higher intensity movements, such as jumping, landing off steps. Then we must add in ball skills, replicating match play. We pushed this player further by having a second therapist jostling with the player as he landed (pushing him off balance as he landed with the ball).

5. Single Leg Landing on Unstable Surface

A player should be able to land on an unstable surface and hold good knee/hip position. If they can achieve this single leg hop onto an unstable surface, they can adequately land while running on grass. This was progressed by having the player catch a ball as he landed.

6. Single Leg Landing Off Unstable Surface Onto Hard Surface

Progressing from the previous exercise, the player had to propel off an unstable surface then land on a hard surface, maintaining good lower limb alignment. It is easy to be pushed off balance by the trampoline then stumble on the hard surface. The player must allow his body to counteract the instability of the trampoline, then produce enough force in his lower limb to propel from an unstable surface with good control, finally absorbing the impact from the hard surface while maintaining good alignment. This is made more challenging when the player has to catch a ball in mid-air, replicating some match day requirements, for this player. 

If you don't have a trampoline, a bosu ball can be used, as long as you place a non-slip mat under the bosu.

The player in these videos has excellent technique, we used various forms of feedback (visual feedback from the mirror, external cues from the therapist and internal cues from his body awareness) to improve his technique. He repeated the exercises until he could complete 10 repetitions with excellent technique. While the player makes these exercises look easy, they are very challenging, especially if the patient/player has underlying strength deficits.

I challenge you to attempt these exercises and feel the control required for these tasks.

Then I challenge you to give some similar exercises to your next high level sports rehab patient, replicating your exercises to the demands of the athlete during match play. It's challenging, requires imagination, but is much more effective than textbook exercises, and I guarantee the athletes will enjoy them a lot more!