Individual case study report

Introduction

Liz, a 25-year-old basketball player for her national team, is returning to play after undergoing a minor ACL tear on her left knee. I have been assigned to work with Lizi on her basketball performance and to reduce the risk of damaging her knee again. As she has been off for several months, she is anxious about playing again.

Despite the advancement in surgical procedures, physicians have continued to report poor ACL-reconstruction. Data by Dunn et al (2010) indicate that less more than 50% of athletes gain their pre-injury level performance after undergoing an ACL reconstruction procedure. Furthermore, for those who manage to return to sport, the risk of re-injury is high.

In a study by Paterno et al (2014), the incidence of re-injury within the first two years after reconstruction was found to be 6 times higher than those who did not have an ACL injury – with the incidence being much higher in female athletes. Similarly, Paterno et al (2014) reported a 29.5% ACL re-injury rate in the second year with 20% of this group experiencing a contralateral injury. But Salmon et al (2005) observed and concluded that the risk of re-injury may extend up to 5 years after injury and reconstruction.

Against this backdrop, it is plausible to claim that Lizi is still at risk of re-injury, and therefore she requires an effective intervention that would prevent this from occurring. This report reflects on a return-to-sport plan that ensures Lizi’s safe and healthy return to basketball playing without episodes of re-injury. In doing so, the report reflect on a need’s analysis for Lizi, develop critically evaluated interventions, and assess the effectiveness of those interventions in achieving the said objectives.

Needs Assessment

A comprehensive needs assessment must be based on a strong understanding of risk factors for re-injury and other factors influencing her safe return to basketball. The risk factors for primary and secondary ACL injury have been a subject of research for a long time now, many researchers gaining interesting insights on the same. For instance, a group of researchers found that biomechanical factors such as females’ increased external knee abduction moment (Hewett et al, 2005), lower extremities side-to-side differences, trunk’s frontal-plane displacement (Zazulak et al, 2007), and reduced activation of lower extremity flexor in the vertical jump have been attributed to ACL injury.

Other pieces of research have also concentrated on deficits in quadriceps weaknesses as a common issue that persists after surgery, and is manifested through abnormal leading patterns in sports and gain activities (Hewett et al, 2013). According to Hewett et al (2013), athletes who have undergone an ACL reconstruction report a quadriceps strength deficit of about 20% compared to the opposite side. Nonetheless, normal neuromuscular control is not associated with even a 90% quadriceps index. That said, the literature highlights four major neuromuscular control deficits that are high-risk factors for ACL re-injury, namely hip rotational control deficits, postural control deficits, knee flexor deficits and excessive frontal-plane knee mechanics (Physiopedia contributors, 2021).

Kinematics and Asymmetry differences in moment arm between involved side joints compared to the other side has also been a presenting complication after ACL reconstruction (Castanharo et al, 2011). In another study by Gupta et al (2020), a follow-up - one year after reconstruction revealed that asymmetry of thigh circumference exceeding 2.5 cm was found to be a significant predictor of ACL re-injury. More, unfortunately, research has found that gender may be a risk factor to ACL re-injury. According to Leys et al (2010), men are more likely to experience graft rapture compared to female. Another study by Shelbourne et al (2009) revealed gender differentials in graft rapture, even though contralateral injuries were found to be higher in females.

The needs assessment must also focus on re-injury prevention. According to ACL Rehabilitation (2021), this prevention requires a better understanding of the risk factors associated with re-injury, so that the rehabilitation program can target all the deficits. For instance, side-to-side quadriceps symmetry would be important for Lizi’s return to sport and the prevention of any future re-injury. The hamstring/quadriceps strength ratio is also an important factor to consider during the rehabilitation process. Ultimately, the rehabilitation process should achieve at least 85% of strength symmetry before Lizi can return to basketball (Hewett et al, 2013).

To effectively evaluate Lizzi’s side-to-side quadriceps symmetry, single-leg plyometric tests would be conducted to give the practitioner an overview of the injured leg functionality and the differences between both sides. The findings of this test would then be incorporated into the rehabilitation program (Physiopedia contributors, 2021). On the same note, in a study by Grindem et al (2016), re-injuries were reported in 38.2% of athletes who failed to adopt a recommended return-to-sports criteria compared to 5.6% of those who passed the criteria. Therefore, a basketball fitness assessment was recommended to ensure that Lizi is not exposed to the risk of re-injury.

Basketball fitness screening

For the game of basketball, the Basketball fitness screening is used to evaluate Lizi’s fitness levels. This fitness test is important because it correlates with how Lizi will perform in a basketball game. That said, the fitness test assessed Lizi’s vertical jump, 2 step approach jump, agility and spirit time and compared them with pre-injury capabilities. It was important to test the height of Lizi’s vertical jump because it indicates how fit she is as well as her ability to get blocks, rebounds and dunks – all of which are crucial in winning a basketball game (Physiopedia contributors, 2021). Sprint speed and agility are also important indicators of fitness because they highlight how fast an athlete can move within the court, how good they are on the offensive, as well as how good they can defend (ACL Rehabilitation, 2021). Lastly, the fitness test also included a body composition test because it would help in identifying Lizi’s level of fitness, as well as the programs that can be developed to optimize the her fitness. The following figures illustrate the results

But Physiopedia contributors (2021) argues that whereas factors such as body mass index, concomitant injury, gender, physical impairments before and after the surgery have a significant influence on the athlete’s expected outcomes after ACL reconstruction, they do not explain a variance in knee function. That said, Logerstedt et al (2012) suggested that conducting a 4-hop test at least six months after the reconstruction has a statistically significant correlation with predicted self-reported knee function. Among these 4 hop steps, the 6-m timed hop and cross-over hop tests were considered the best predictors.

Ideally, according to ACL Rehabilitation (2021), the 6-m hop timed highlights asymmetries and predisposes the knee in neuromuscular control challenge. Therefore, conducting these tests on Lizi before putting her on a sport-specific training would help in identifying and addressing the deficits that may expose her to ACL re-injury. During the test, the following factors can help predict lizi’s return to pre-injury status (Lentz et al, 2012): decreased episodes of knee giving way, lower intensity of knee pain, decreased knee effusion, decreased kinesiophobia levels, and an increased quadriceps peak torque-body weight ratio.

Psychological fitness screening

The influence of psychological factors on effective sports resumption after ACL reconstruction cannot be ignored. Lentz et al (2015) observed that pain-related fear significantly distinguishes between athletes who can and who cannot be able to return to their pre-injury level of sports activity. On the same note, Lentz et al (2015) argued that fear and lack of confidence have a significant influence on function. Therefore, the assessment of these factors must be included in Lizzi’s rehabilitation plan. Considering that Lizi is anxious of playing again, it is important to assess her anxiety levels and know whether it can affect her competitive basketball resumption. The Competitive State Anxiety Inventory (CSAI-2) can be effective in measuring Lizi’s anxiety levels. It uses a four-point scale questionnaire that ranges from ‘not at all’ to ‘very much’ to measure the responses categorised into three major factors namely: confidence, cognitive anxiety and somatic anxiety. The following table illustrates the results from Liz’s CSAI-2 assessment (the higher the score, the more anxious Lizi is):

Lizi’s cognitive anxiety may present in different ways including worry, thoughts, and nervousness (Physiopedia contributors, 2021). On the other hand, somatic anxiety may present in the form of sweaty palms, increased heart rate and muscle tension. Lastly, low confidence levels may present in the form of fear, introverted behaviour and self-doubt.

As highlighted in the above results, various interventions should be adopted to address Lizi’s anxiety levels. This is because higher anxiety levels affect athletes ‘motivation for participation (Physiopedia contributors, 2021). It is important to incorporate this into Lizi’s rehabilitation plan otherwise she might opt to discontinue with the rehabilitation process. This proposal corroborates with the findings of Grindem et al’s (2016) study, whereby 45% of the community-level athletes discontinued rehabilitation three months after reconstruction due to lack of motivation.

Even if Lizi does not discontinue the rehabilitation program, she might opt not to go through all the stages required to have her return to full-time basketball playing. She may feel competitive and ready at the initial stages before passing all the stages, and this may discourage rehabilitation before she regains all the criteria for her to join full-time playing.

Interventions

For basketball fitness, a set of interventions were developed for Lizi that fit within four major stages namely: core strengthening and dynamic stabilization, power development, functional strengthening and sports performance asymmetry. This protocol majorly sought to recondition Lizi to an extent that she can have an optimal physical functioning – by minimizing the risk of re-injury and targeting her neuromuscular deficits.

Core strengthening and dynamic stabilization

The aim of this intervention is to improve Lizi’s single-limb weight bearing function to facilitate a greater knee flexion angle, to improve the single-limb posture balance on her closed chain, and to improve her lower extremity symmetry. According to Physiopedia contributors (2021), a stronger core will enable Lizzi to control the deceleration of her centre mass with a balanced posture; and to be able to accelerate her mass rapidly through a controlled force. As Battaglia et al (2007) highlighted, deficits and weaknesses in the hip and trunk musculature correlate with ACL injuries and biochemical abnormalities, especially in female athletes.

Examples of exercises to be used in this stage include: Back extension, Bridges, Single leg bridges, Crunches Reserve crunches, Diagonal crunches, V sit and stretch V sit and twist (Appendix 1 illustrates these activities in detail).

Functional strengthening

The main objectives of this set of activities is to improve load distribution pattern over the two lower extremities, especially during activities that require a stance on the two legs, improve Lizi’s single leg landing force attenuation strategies, as well as to improve her load distribution pattern over both lower extremities during activities that require a stance on both legs. Even as she continues with core strengthening and dynamic stabilization, it is important to introduce progressive lower extremity strengthening, while gradually adding more resistance without compromising her already good form. Some of the exercise activities reccomended in this stage include: Leg press 5 reps on each leg, Squat and heel, Squat and reach, Hip adduction, Hip adduction, Hip adduction, Hip extension, Knee extension, Forward skip, Backward skip, Side skip, Side shuffle. Appendix 1 illustrates these activities in detail.

Power development

The main aim of this stage is to enhance Lizi’s power production in the lower extremity. Furthermore, as Myer et al (2008) suggested, it would involve training Lizzi on how to perform plyometrics and resist fatigue, the former with good biomechanics. Therefore, this training would incorporate some balancing exercise including: Walk and hold single leg, Front and back rock, Single leg, Plyo ball sit and rock, ingle leg hops for height, and Single leg hops for distance.

Basketball performance asymmetry

This stage seeks to train Lizzi on how to use safe biomechanics in high intensity plyometric exercises, to produce symmetrical power between both lower extremities and to maintain dynamic knee stability through high intensity change of activity directions (Myer et al, 2008). However, this stage requires both visual and verbal feedback because increased valgus angle can cause injuries especially in females. When the knee has vulgas loads, they can double during an unexpected manoeuvre (Physiopedia contributors, 2021). Therefore, it would be necessary to teach Lizzi how to move in a manner that reduces low knee abduction which can produce high loads on the joints and consequently increase the risk of injury (Myer et al, 2008).

Psychological interventions

An assessment of Lizi’s competitive anxiety levels indicated that her cognitive anxiety, somatic anxiety and confidence levels needed some rehabilitation. Therefore, the following section illustrates the various strategies suitable for improving her psychological well-being.

One of the interventions I proposed for Lizzi’s cognitive anxiety is optimism and mental imagery. According to Shepardson et al (2018), an individual’s ability to develop vivid positive mental imagery over a phenomenon of their life can be associated with dispositional optimism, boosting their confidence over the challenges they face (Ophuis et al, 2020). Therefore, by boosting Lizzi’s positive future imagery, she can acquire a cognitive target that promotes her confidence and optimism towards her capabilities, with positive implications on both her physical well-being and mental health.

Meditation also presents as a solution that has popularly been used to treat anxiety – through cognitive behavioural therapy. According to Ponting et al (2020), meditation is useful for both somatic and cognitive anxiety because it modifies the dysfunctional cognitions held by patients with anxiety disorders. Similarly, a study by Shepardson et al (2018) found that cognitive restructuring and mindfulness medication were some of the most effective interventions for handling worry problems such as worry postponement, problem solving and worry exposure.

For somatic anxiety, I recommended progressive relaxation as a good intervention. According to Shepardson et al (2018), it involves alternating relaxation and tension in the body’s major groups of muscles. Due to anxiety, Lizzi’s muscles are probably tensed, and therefore progressive relaxation would help her relax the tensed muscles. While this technique can be used alongside other forms of cognitive behavioural therapies, using it alone would help Lizi to have control over her anxiety levels (Ophuis et al, 2020).

Assessing the interventions

Evidence by Barber-Westin et al (2011) indicate that athletes may still experience deficits in muscle strengths months after ACL reconstruction. Similarly, a study by Deneweth et al (2010) found abnormal knee (Barber-Westin et al, 2011) kinematics up to a year after ACL reconstruction. On the same note, the systematic review by showed how many studies found that in order for an athlete to have clearance to return to sport after ACL reconstruction, their isokinetic testing must be at 180°/s and 300°/s, indicating a less than 10% deficit in hamstring and quadriceps strength; normal patellar mobility, painless activities, no swelling, slight or no patellar crepitus and absence of effusion. Moreover, other criteria may include performing a video jump test to ensure that she has attained a more than 60% of normalized knee separation distance (Physiopedia contributors, 2021).

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Appendix 1: Basketball Fitness Activity Plan