This example is of a rugby player with a knee injury early in the 2002-2003 season. Obviously, all cases are different and need to be approached individually, but as the rehabilitation of this athlete went very smoothly, I thought it would make an interesting success story. My involvement was as the strength and conditioning coach who designed the rehabilitation programme in conjunction with the physiotherapist.
The strain was only partial, and so no surgery was required. The athlete used a knee brace to make sure there were no lateral forces while the knee was at its weakest and the ligaments were healing. Once the swelling began to reduce, the athlete performed gentle mobility exercises of the knee joint and received some treatment to promote healing.
A split-routine programme
During this time, she completed upper-body weight-training 6 days per week. To allow the athlete to train every day, we designed a split-routine programme, working chest, front shoulder and triceps on one day and back, rear shoulder and biceps on the following day. We also included exercises for the trunk and straight leg deadlifts for the gluteals and hamstrings. From a psychological point of view it was very important for her to use the rehabilitation period productively. Time out from injury is depressing for most athletes, especially at the start of a season. Consequently, in this case, the athlete was working very hard in the gym to take her mind off the fact she was injured.
After six weeks, a scan showed that the medial ligaments had healed very well and the knee became stable once again; however, the athlete retained the knee brace for safety. We introduced gentle exercises for the quadriceps, focusing on maintaining alignment of the knee joint with the hip and ankle. To begin with, these were basic bodyweight squat exercises, and small knee bends on a step or stair. At first, the knee was a little wobbly while the athlete had to learn to flex and extend the knee smoothly, but the co-ordination soon returned.
Once the athlete's confidence was stronger, we started to use the barbell squat exercise to develop the strength of the quadriceps (see picture ).
Why the squat works
Some therapists and trainers may feel the squat is a little risky for knee-injury rehabilitation programme; I would argue it is the best choice.
First, although there is some compression of the knee joint at the low point of the squat, as shown, the forces on the knee ligaments are moderate, comfortably in the tolerance range. Second, the squat is a highly functional exercise. The quadriceps muscles are very active during the movement, as are the gluteals. The knee joint is flexing and extending concurrently with the hip and ankle, which means the muscles learn to produce force in an integrated fashion. The exercise is also ground-based. To perform it correctly,
the athlete must retain balance and alignment of the knee and stability
of the low back. All these factors mean that for rehabilitating the knee
joint and developing strength
and quadriceps, the squat is a high-value exercise.
In this case the athlete started with a squat using a 30 kg weight (compared to the weight previously in training before the injury of 80-110 kg). Over a four week period, she slowly progressed to 70 kg.
Over the same period, the athlete introduced jogging to the rehabilitation programme. This involved three runs per week. In the first week, each run lasted only six minutes at 10 kph. This progressed to eight minutes and then up to 20 minutes in two or three minutes steps as the athlete gained in confidence. This may seem very cautious, but it is a strategy I have found to be very successful. One has to remember that even in a six- minute run the athlete is likely to make around 500 steps each leg, which is a high number of repetitions for a knee joint recovering from an injury.
The final phase of the rehabilitation programme involved introducing jumping and agility exercises. The difficulty of the exercises was decided by the physiotherapist, and they started at quite a basic level, such as simple lateral hopping from side to side, without jumping upwards. The difficulty of the endurance sessions increased to interval training with shuttle runs.
The shuttle runs introduced a change of direction element to the workout, while getting the heart rate high on the intervals. Four sets of 5 x 30 seconds with 20 seconds rest using a 20-metre shuttle was used for this. This is the sort of session that gives athletes confidence that they are nearly ready to play rugby again. Soon after this, the athlete in this study started to join in club training sessions that did not involve contact. Two weeks after this she played in her first full match.
This account may sound a little basic, but I feel there is no need to be over-complex with rehabilitation programmes as long as all the important elements are covered. These are: full healing of the tissue, regaining of mobility followed by regaining of strength and proprioception. At the same time, the athlete needs to work on cardiovascular conditioning. Lack of fitness would increase the athlete's risks of breakdown once she resumed playing the sport again. In this case, I believe the use of the barbell-squat exercises was very important in re-establishing strength and function of the knee joint.