[
clinical commentary
]
ERIC WATERS, MS, ATC/L, CES, CSCS1
Suggestions From the Field for
Return to Sports Participation
Following Anterior Cruciate Ligament
Reconstruction: Basketball
M
ketball or reacting to an offensive
ost anterior cruciate ligament (ACL) injuries in
player. Once the player satisfies
basketball are noncontact in nature. The typical
the criteria for each phase and
SUPPLEMENTAL
mechanisms of ACL tears in basketball include forced
VIDEO ONLINE
meets the return-to-play criteexcessive valgus stress at the knee, excessive femoral
ria (APPENDICES A and B), she/he
internal rotation on the tibia, excessive anterior translation of the tibia may begin practice, initially with restricon the femur, or a combination of the above. As most ACL injuries tions, before returning to play without
in basketball occur from a planting, decelerating, pivoting moment restriction.
or landing from a vertical leap, the rehabilitation protocol should prepare
the player to avoid these risk-associated
positions by addressing proper landing
mechanics, hip abduction strengthening,
cocontraction of the quadriceps and hamstrings for joint stiffness, balance, and
proper trunk and knee flexion. Only after
TTSYNOPSIS: The purpose of this paper is to
outline the final, functional phases of rehabilitation
that address exercises, drills, and return-to-play
criteria for the sport of basketball, following anterior cruciate ligament (ACL) reconstruction. ACL
injuries can be debilitating and affect the quality of
life for recreational and elite athletes alike. Tears
of the ACL are common in both male and female
basketball players, with a higher incidence rate
in females. Incidence of a retear to the existing
graft or contralateral knee within 5 years of ACL
reconstruction with patellar tendon autograft in
young (less than 18 to 25 years of age), active basketball players can be as high as 52%.
Reducing the number of ACL injuries or reinjury,
of which there are an estimated 80 000 per year
these impairments are addressed can the
final, functional return phase begin. This
final phase of the protocol must seek to
challenge the basketball athlete by mimicking the demands of the sport, which
include single-leg jumping, landing, and
other deceleration skills executed while
dribbling, passing, and rebounding a basat an associated cost of over a billion dollars, can
have significant potential long-term fiscal and
health benefits. Following surgical reconstruction
of the ACL, implementing a tailored rehabilitation
protocol can ensure a successful return to sport.
When searching the literature for such protocols,
clinicians may struggle to find specific exercises,
drills, and return-to-play criteria for particular
sports. The intent of this manuscript is to present
such a rehabilitation protocol for basketball.
TTLEVEL OF EVIDENCE: Therapy, level 5. J
Orthop Sports Phys Ther 2012;42(4):326-336.
doi:10.2519/jospt.2012.4030
TTKEY WORDS: ACL, functional rehabilitation,
injury, jumping, landing, NBA
There is scant literature addressing
rehabilitation protocols, exercise progressions, and return-to-play criteria
specifically for basketball athletes (particularly males) following ACL reconstruction. The goal of this article is to address
the current deficiency of the rehabilitation literature by providing a framework
of functional drills and return-to-play
criteria specific to the basketball athlete
(high school to elite level) recovering
from ACL reconstruction surgery.
FUNCTIONAL REHABILITATION
PHASES
P
rogression criteria and the
outline for rehabilitation of the basketball athlete following ACL reconstruction include 3 phases (APPENDICES
A and B). Phase 1 addresses immediate
postsurgical needs, from wound care to
the initiation of range of motion (ROM)
and general strength acquisition. Phase 2
provides a platform for gaining full ROM
Head Athletic Trainer, Washington Wizards Basketball Club (NBA), Washington, DC. Address correspondence to Mr Eric Waters, Washington Wizards, Sports Medicine, 601 F St
NW, Wizards Athletic Training Room, Washington, DC 20004. E-mail: [email protected]
1
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FIGURE 1. Rotational squat, starting position.
FIGURE 3. Split squat on foam pad with dribbling.
FIGURE 5. Double-leg BOSU ball squat with dribble.
FIGURE 2. Rotational squat, finishing position.
and strength, while providing a base for
neuromuscular coordination and endurance exercises. Phase 3 seeks to progress
the athlete from the beginning of functional work at the end of phase 2 to final
return to play through higher-intensity
functional rehabilitation.
FIGURE 4. Double-leg tilt board squat with dribble.
will concentrate on the functional aspect
of rehabilitation found in phases 2 and 3.
Phase 1
The first phase of most rehabilitation
programs following ACL reconstruction
focuses on similar goals, without much
sport specificity.7,22 These goals focus on
ROM and strength gains, return to normal ambulation, performance of trunk/
hip strengthening and simple groundbased balance exercises, and cardiovascular work. Light sport-specific work
may be included during the latter stages
of this phase (stationary drills such as stationary ball handling, passing, and freethrow and spot shooting). This article
Phase 2
During phase 2, initiated approximately
10 to 13 weeks postsurgery or when the
progression criteria are met (APPENDIX A),
the goals of phase 1 are continued, with
ROM gains, lower extremity strengthening, and low-intensity agility/neuromuscular drills as the primary goals.9,20,22,25
Phase 2 functional strengthening and
neuromuscular enhancement, in preparation for phase 3 power and basketball-specific work, may be completed
concurrently. It consists of exercises de-
signed to develop strength through functional movements and power and force
attenuation skills from low-intensity
jumping and landing drills.18
Functional Strength Functional strength
enhancement is accomplished with
weight-bearing (closed-kinetic-chain)
exercises, progressively increasing the
amount of weight the athlete can move,
while concurrently maintaining proper
lower extremity alignment.8 The role of
the rehabilitation clinician is to construct
exercises that address existing deficits
and to provide feedback to the patient
that will allow the patient to maintain
suitable alignment during the exercises.13,26 Following the restoration of baseline bilateral lower extremity strength, as
achieved in phase 1 by exercises such as
squats (single-leg and double-leg), rotational squats (FIGURES 1 and 2), wall slide,
leg presses, and hamstring curls, progression to the functional strengthening
aspect of ACL rehabilitation can begin.36
The single-leg squat exercise is a basic
but vital form of functional strength enhancement.8,20,26,29 It requires the patient
to effectively transmit loads through the
lower extremity to the ground, to create
the most linear and stable vector movement. This is critical for the basketball
athlete, particularly during the initiation
of a drive to the basket or leaping verti-
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[
clinical commentary
]
FIGURE 9. Double-leg ball catches on a tilt board,
while clinician provides external perturbations.
FIGURE 12. Crab dribble drill with elastic resistance.
Player slides back and forth between 2 points while
dribbling.
FIGURE 6. Single-leg squat on tilt board with dribble.
FIGURE 10. Single-leg ball catches on a tilt board,
while clinician provides external perturbations.
FIGURE 7. Double-leg squat on BOSU, with ball
catching and passing.
FIGURE 11. Single-leg hop drill with elastic resistance.
Player hops in the direction commanded by the
clinician, while holding posture and lower-body
alignment.
FIGURE 8. Single-leg squat on BOSU, with ball
catching and passing.
cally for a layup. The initial functional
strength exercises, such as the single-leg
squat, rotational squat (FIGURES 1 and 2),
split squat (FIGURE 3), and low-level double-leg and single-leg hopping and landing (FIGURE 11, ONLINE VIDEOS 1 through 4),
are designed to effectively integrate all
movements while enhancing strength
and joint stiffness.
Neuromuscular Enhancement Drills In
addition to initial power, strength, and
ROM gains, acquisition of balance, kinesthetic awareness, and neuromuscular coordination is a critical goal of this
phase. Balance training on perturbation
devices, such as BOSU (BOSU, Canton,
OH), tilt board, and foam pads, is introduced (FIGURES 3 through 10). In addition,
low-intensity jumping and landing drills
(both double- and single-leg) (FIGURE 11,
ONLINE VIDEOS 1 and 2), cutting drills, and
lateral-movement drills while catching,
dribbling, and passing a basketball may
FIGURE 13. Defensive slides with elastic resistance.
The player executes defensive slides around an
arc, while maintaining posture and distance from
clinician.
be implemented (FIGURES 12 through 14,
ONLINE VIDEOS 3 through 5). Elastic resistance may be added to challenge balance and increase cocontraction and
joint stiffness of the lower extremity.
Basketball shooting and passing drills
with low-intensity movement may also
be introduced at this stage. These exercises lead to early-stage re-education of
the neuromuscular mechanisms that promote dynamic knee stability.26,31,34 Proper
posture upon landing should include pelvic stability, trunk flexion, and knee flex-
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FIGURE 14. Close-out drill. With elastic resistance
added to aid in increasing eccentric load, the player
accelerates to and decelerates to close out on an
offensive player in a controlled manner.
FIGURE 16. Zigzag drill. Sprint into a diagonal cut at 45° around each cone, with or without dribbling a
basketball.
for phase 3 is highlighted by the introduction of low-intensity neuromuscular training, movement mechanics, and
functional drills that will be carried over
to phase 3 at higher intensities. Strength,
power and ROM work, cardiovascular
training, and core strengthening and stability are also continued in phase 3.
FIGURE 15. Low-post drill. Player with ball attempts
to score in the low-post area while being resisted.
Player may switch roles to be the resistance provider.
Phase 3
ion without frontal or transverse plane
movements at the knee.8,14,23,26 To achieve
proper lower extremity alignment during drills, the clinician may be creative
in introducing these types of exercises;
however, vigilance must be maintained in
providing feedback for the athlete should
she/he begin to lose proper pelvic and
lower extremity alignment. Use of video
(ONLINE VIDEOS 1 and 2) is especially helpful to provide feedback on all functional
exercises being introduced, particularly
in landing drills.
The idea of phase 2 as a staging phase
This final phase should include a functional-rehabilitation progression that addresses the most demanding components
of basketball. This phase is divided into
3 elements that should be executed concurrently: continued muscular strength,
power, and endurance enhancement;
basketball agility drills; and return to
basketball play criteria and progression
(APPENDIX B).33
Muscular Strength, Power, and Endurance Enhancement To enter phase 3, it
is imperative that athletes meet the criteria that permit them to successfully
execute the higher-intensity work. This
includes proper gait mechanics,11 adequate concentric and eccentric strength
(measured by isokinetic testing),37 power
production, cutting and landing skills
(single-leg and double-leg), and muscular and cardiovascular endurance
(APPENDIX B).12,17,33,37 Working on power
production has the added benefit of enhancing both muscular endurance and
strength.4,7 Low-impact single-leg and
double-leg plyometric exercises, such as
lateral hops (with or without resistance)
(FIGURE 11), single-leg lateral hops while
dribbling or catching (ONLINE VIDEOS 6 and
7), and box jumps, are initiated. Examples of advanced power-based exercises
that address muscular strength, power,
and endurance include single-leg and
double-leg tuck jumps, repeat vertical
box jumps (30-cm and 45-cm boxes),
split-squat scissor jumps, and single-leg
hops with 90°/180° turns while catching
and passing a basketball (ONLINE VIDEOS 8
and 9). These exercises address proper
creation and dissipation of force and efficiency of movement without lateral pelvic
excursion or poor lower extremity alignment. Basketball passes and catches may
be added to these exercises to increase
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[
clinical commentary
Backpedal
Sprint
FIGURE 17. Sprint-backpedal drill. Accelerate to the cone, decelerate, backpedal to the baseline, and repeat, with
or without dribbling a basketball.
Defensive slide
Backpedal
Sprint
Defensive slide
FIGURE 18. Box drill. The patient must continuously move around the basketball lane in the manner shown. The
clinician may call for a change in direction (counter versus clockwise) at any time.
]
difficulty and reflect game situations that
require reaction.
Basketball-Specific Agility Drills Once
the athlete meets the progression criteria (APPENDIX B), the athlete may progress
to movement in all planes at different
speeds, provided there is gradual increase in the intensity and difficulty of
the movements prior to performing fullspeed running, cutting, jumping, and
landing. Developing agility requires that
the patient relearn intricate footwork
and movement patterns that challenge
the neuromuscular and proprioceptive
systems.2,10 Basketball-specific movement drills may be divided into skill
drills, reactive drills, contact drills, and
a combination of each of these. These exercises must include not only proactive
movement patterns and skills, such as
initiating a sprint to the basket to score,
but also reactive-movement sequences,
which include moving laterally while
dribbling (FIGURE 12, ONLINE VIDEO 13), defending an opposing player (FIGURE 13, ONLINE VIDEO 14), or “closing out,” in which a
defensive player sprints to an offensive
player to defend a shot or drive to the
basket (FIGURE 14, ONLINE VIDEO 15). Different players (guard, forward, center)
require drills specific to their positions.
Increasing the area over which the drill
is performed, decreasing the rest periods, adding ball handling, passing, and
catching, and increasing the speed and
intensity of the movements and cuts
can increase the difficulty of the task
and provide a progression component
to this portion of the rehabilitation.
Once these skills are relearned and the
involved lower extremity is symmetrical
in function and alignment to the uninvolved limb at high speed and effort, the
athlete can safely begin high-intensity
basketball-type activities, such as defensive and offensive drills, contact drills,
and shooting drills, during practice (FIGURE 15). This is followed by return-to-play
testing.20,31
The zigzag drill (FIGURE 16, ONLINE VIDEO
16) is designed to address acceleration
and deceleration associated with the lat-
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eral cuts or V-cuts that are commonly
performed by all basketball players. Accelerating to a sprint forward, the player
reaches a cone and takes a 45°-angle cut,
accelerates for a few steps, takes another
45° cut back through the cones, and continues this through several more cones.
Adding ball handling to this drill, with
right- and left-hand crossover dribbles
or catching and throwing passes at the
cut points, is effective in adding difficulty.
The sprint-backpedal drill (FIGURE
17, ONLINE VIDEO 17) adds deceleration to
a backpedal component. Closing out or
accelerating to an opponent and then
decelerating as the player reaches the
opponent is an important skill to regain.
In this drill, the player sprints to a cone
at a 30° to 45° angle, stops at the cone,
then backpedals at an opposite 30° to 45°
angle to the start line, and continues on
for as many cones as desired.
The box drill (FIGURE 18) uses the
basketball lane area as a template. The
player sprints forward along the lane and
decelerates at the free-throw line, where a
lateral defensive slide begins to the opposite side of the lane, before backpedaling
to the baseline. This is done repeatedly,
with the direction changed on command
from the clinician. Forwards and centers
may be asked to touch the backboard
each time they reach the baseline, and
guards and forwards may be asked to
pass-catch or dribble through the entirety
of the drill.
The star drill (FIGURE 19, ONLINE VIDEO
18) is a reaction drill that focuses on the
player’s ability to react to a verbal command to change direction of movement.
A series of cones or spots are numbered 1
through 4 (or more). The player is placed
in the middle of these cones. Once a number is called out, the player must sprint,
with or without dribbling a basketball, to
that number, then return to the original
position, and the exercise is repeated.
In the ball chase drill (FIGURE 20, ONLINE
VIDEO 19), starting in any spot on the court,
the clinician holds 2 basketballs while
facing the player. The clinician throws
1 ball anywhere on the court. The player
1
2
Start
4
3
FIGURE 19. Star drill. The clinician calls out a number, the patient must run to that number and back to the
starting point, where a new number is called out for the patient to run to. Basketball dribbling may be added for
functionality.
Player
Clinician
FIGURE 20. Ball chase drill. The clinician uses 2 balls, tossing one in a random area of the half court. As the player
moves as quickly as possible to retrieve the first ball, the clinician tosses the second ball to another random area
for the patient to retrieve. This can be done with as many repetitions as desired.
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must sprint to the ball and either dribble
it to or pass it to the clinician. Just before
the clinician receives the ball, the clinician throws the other ball to another spot
on the floor, challenging the reactivity of
the player to visual cues. To increase the
difficulty, the player can be asked to dribble the ball to a predetermined spot and
shoot the ball. As she/he shoots the ball,
another ball is thrown somewhere else on
the court of play, continuing the drill.
Contact in basketball may also lead
to ACL injury.1,3 Therefore, it is crucial,
physically as well as mentally, that a contact component is added to the program
prior to the return to sport. Designed
for guards and forwards, the gauntlet
drill (FIGURE 21) focuses on the contact
a player will make in driving through
the lane during play. Several clinicians,
coaches, or players line up on each side
of the predetermined lane to the basket.
Each holds a common handheld basketball pad. As the player drives to the basket, clinicians (or assistants) are asked
to lightly tap the player with the pad as
the player dribbles through the lane. The
speed of the player and heaviness of contact may increase over time, provided it is
done in a controlled manner.
The low-post drill (FIGURE 15, ONLINE
VIDEO 20) utilizes a coach, player, or clinician to provide resistance to the back of
the low-post player (a forward or center)
as the player turns and makes a low-post
move. These players often play with their
back to the basket and close to the basket, and are often resisted in their efforts
to go to the basket. Providing resistance
and attempting to push them off balance
helps them regain those skills. The player
is also asked to play the defensive portion
of this drill to react and resist the movement of the opposing player. The clinician
should look for the player’s willingness to
play in a protected position, with knees
and trunk flexed while exhibiting pelvic
stability.18,23
Landing off balance after being
pushed while in the air is a common
mechanism of ACL injury in basketball.
The leap-contact drill (ONLINE VIDEOS 21
]
Player
Clinician
Clinician
Clinician
Clinician
FIGURE 21. Gauntlet drill. As the player dribbles the basketball down the lane, the clinicians gently tap the player
with pads to resensitize the player to contact they are accustomed to within the lane.
and 22) is intended to re-establish confidence in the athlete’s ability to land with
proper lower extremity mechanics. The
player is asked to jump from the ground
or a 30-cm box and, while in the air, is
tapped by the clinician to push the player
off the line of landing. The player is expected to land in a protected position
(knees and trunk flexed with no valgus
alignment at the knees) on both feet.26
Progressions include landing on 1 foot
and adding jogging prior to the jump.
These contact drills must be done in
a controlled manner and only in the final phases of the ACL rehabilitation program. This drill should precede return to
full-contact practice situations.
Return-to-Basketball Criteria and Progression When making the decision to
return to basketball-specific sports participation following ACL reconstruction,
very few evidence-based criteria exist.21,32
Typically, once the player is cleared in
terms of objective criteria (APPENDICES
A and B), the player is allowed to start
practice activities that are noncontact
(shell drills, shooting drills, defensive
drills, offensive sets), while the intensity
of the activity is gradually elevated. Contact drills are allowed when the player is
able to go through noncontact drills at
full speed, without pain or swelling and
with full confidence. It is important to
note that gaining the compliance of the
coaching staff is helpful in structuring the
return to full practice participation. The
clinician and basketball player face many
challenges in determining the right time
to return to play.7 The psychological component must also be considered,6,35 as the
player must feel confident in his/her ability.6 The team personnel (team psychologist, physical therapist, athletic trainer,
and coaching staff ) may play an important role in gaining this perspective.
Cardiovascular fitness is an important
factor in the return-to-play scenario. Zebis et al38 noted that acute fatigue can
lead to compromised neuromuscular
activity in professional handball players.
Cardiovascular fitness testing (of both the
aerobic and anaerobic systems) is necessary for a safe return to play.33 The final
stages of return to play are highlighted by
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controlling practice time by monitoring
heart rate, recovery, tracking body mass
index, and other parameters that are beyond the scope of this article.12 Once the
player, clinician, and coaching staff feel
that there has been adequate recovery
between bouts of practice (water breaks,
free-throws, timeouts) for an entire practice session, it is inferred that the player
is capable of returning to full practices
without limitations.
Once all criteria are met, the player
may return to competitive basketball.
At the elite level (professional and collegiate), monitoring player minutes during
competition has been shown to be useful in avoiding excessive fatigue. Minute
allocations should be decided by consensus of the player,19 physician, physical therapist, athletic trainer, and coach.
According to the National Basketball Association’s injury surveillance from 1998
to 2011, 74% of all ACL injuries occurred
during in-game competition. Because
game situations provide the most exposure, monitoring player minutes may
prevent fatigue38 and allow some control
over reinjury.
Gender Considerations
It is reported that female basketball
players sustain ACL injuries 3.5 to 9
times more frequently than male players.1,3,5,13,24,30 Despite the great difference
in injury rates between these 2 groups,
the underlying tenets of sound movement mechanics (landing with less
ground reaction force; greater flexion
angles at the hip, knee, and ankle; and
reduced valgus moment at the knee, etc)
must be achieved in the rehabilitation
protocol.24,27,28 Due to the anatomical,
neuromuscular, and strength differences
between female and male athletes, timelines for return to play may be expanded
for female athletes.13-16,36 Therefore, when
retraining basketball athletes following
ACL reconstruction, it is valuable to not
only restore preinjury cutting, jumping, and landing capabilities but also to
enhance them.11,18 This goal can be met
equally for both men and women, pro-
vided their existing deficits in neuromuscular firing patterns, strength, and body
position are identified by the clinician
and corrected.26,29,31
CONCLUSION
3.
F
4.
unctional rehabilitation following ACL reconstruction surgery for a basketball athlete poses
a unique challenge for the athlete and
the physical therapist. The amount of
high-speed cutting, pivoting, and, most
notably, explosive jumping (and landing)
from full sprints may place the athlete
in compromising positions. Preparing a
basketball player for an effective return
to play requires that the final and most
functional phase of the rehabilitation
program encompass a thorough protocol
based on exercises that maintain proper
lower extremity alignment throughout all
the conceivable scenarios of a basketball
game. To achieve this goal, a successful
rehabilitation program must take into
account these unique movements, fitness
level, player positions, and even gender.32
It should also contain basketball-related
exercises and progressions that specifically address these movements. Examples include drills that challenge the
player in different phases of the game of
basketball, such as dribbling, passing,
and catching a ball while running, cutting, and jumping, as well as reacting to
ball and player movement. It is the role
of the clinician to provide these unique
challenges during the functional aspect
of the rehabilitation process and to supply feedback to the player to ensure that
proper lower-body strength, power, and
stability are achieved for a successful return to play. t
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APPENDIX A
REHABILITATION GOALS AND RETURN-TO-PLAY CRITERIA (PHASE 1 TO PHASE 3)
FOLLOWING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN A BASKETBALL PLAYER
Phase 1 (Weeks 0-10 to 0-12, or Progression Criteria Met)
Goals
• Decrease swelling
• Pain management
• Restoration of full knee extension and flexion compared bilaterally
• Non–weight-bearing strengthening exercises for hip, quadriceps, hamstrings, lower leg
• Introduction of weight-bearing strengthening for ankle, quadriceps, and
gluteals; core strengthening; weight-bearing/balance training
• Begin cardiovascular training: stationary bike, elliptical trainer, upperbody ergometer
• Begin stationary ball handling, free-throw shooting, spot-shooting drills
Phase 1 to Phase 2 Progression Criteria
ROM criteria:
• Near full extension
• Flexion of at least 120° (overpressure)
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APPENDIX A
Strength criteria:
• Push strength of at least 50% of uninvolved side on the leg press
• Good quadriceps contraction in extension
• No extensor lag
• Progressively increasing strength in ankle plantar flexion
• Single-leg bridging
• 4-way hip movements
• Internal and external hip rotation
General criteria:
• Patellar mobility: progressively increasing patellar mobility
• Pain: little to no pain during ambulation
• Swelling: mild to no swelling following rehabilitation and activities of
daily living
• Kinesthetic awareness: increasing ability to balance on involved lower
extremity
Phase 2 (Weeks 13-19, or Progression Criteria Met)
Goals
• Continuance of phase 1 goals
• Regain primary strength of gastrocnemius/soleus, quadriceps/hamstrings/gluteals, pelvic girdle equal to uninvolved side
• Balance and kinesthetic awareness enhancement
• Begin low-load jumping and landing skills and testing
• Begin straight-ahead running mechanics
• Begin low-intensity cutting mechanics, low-intensity acceleration/
deceleration drills
• Progress to advanced cardiovascular training: treadmill running, oncourt running, sustained shooting drills
• Continue ball-handling/shooting drills, begin moving with ball, dribbling
with the basketball, and low-intensity on-court drills
Phase 2 to Phase 3 Progression Criteria
ROM criteria:
• Near full extension passively
• Flexion of 130° (overpressure)
Strength criteria:
• Push strength of at least 70% of uninvolved side on the leg press
• Isokinetic flexion/extension within 70% of uninvolved side at 60°/s,
180°/s, and 300°/s
• Single-leg squat of near equal depth of uninvolved side
• Single-leg bridge strength 80% of uninvolved side
• Hip internal/external rotators strength 80% of uninvolved side
• 4-way hip strength within 80% of uninvolved side
General criteria:
• Patellar mobility: near full mobility compared bilaterally
• Pain: little or no pain during or after rehabilitation process
• Swelling: mild to trace swelling following rehabilitation and activities of
daily living
• Power: ability to do vertical 15-cm box jumps, forward, left, and right,
with good control of hip and knee
• Kinesthetic awareness: increasing ability to maintain balance during perturbation drills, ability to land from 10-cm and 15-cm boxes in
forward and right and left landing jumps with proper hip and lower
extremity alignment
Basketball-specific criteria:
• Ability to maintain lower extremity alignment and balance during defensive slide (FIGURE 13, ONLINE VIDEO 3), crab dribble (FIGURE 12,
ONLINE VIDEO 4), crossover step (ONLINE VIDEO 5), lateral hop with
dribble (ONLINE VIDEO 6), and lateral hop with catch drills (ONLINE
VIDEO 7)
APPENDIX B
REHABILITATION GOALS AND RETURN-TO-PLAY CRITERIA
(PHASE 3 TO UNRESTRICTED ACTIVITY) FOLLOWING ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION IN A BASKETBALL PLAYER
Phase 3 (Week 20 to Unrestricted Activity or When Return-to-Play
Criteria Are Met)
Goals
• Continuance of phase 1 and 2 goals
• Continue strength, power, agility, basketball skill acquisition
• Continue functional strength and power enhancement
• Continue eccentric strength and force attenuation enhancement
• Progress basketball skill work, agility, and neuromuscular development
• Return to full basketball participation: cardiovascular testing, practice
structuring, and game minutes allocation
Range of Motion (ROM) Criteria7
• Full knee extension bilaterally16
• 1 35° of flexion, while progressing to full flexion bilaterally, ideally heel
to rear28
Strength Criteria
• Knee extension strength (isotonic): 90% of uninvolved side, 3-repetition maximum19
• Hamstring curl strength (isotonic): 90% of uninvolved side, 3-repetition
maximum19
• Leg-press strength (isotonic): 90% of uninvolved side, 3-repetition
maximum
• Single-leg squat test: 90% of uninvolved side, 10 repetitions with equal
bilateral mechanics of uninvolved side with 18.14-kg weight vest and
equal ROM depth of uninvolved side
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[
clinical commentary
]
APPENDIX B
Power Criteria
• Hamstrings/quadriceps power production (isokinetic): 85% of uninvolved side at 60°/s, 180°/s, 300°/s
• Rotational power squat test: cable resistance (isokinetic readout or
6-repetition maximum; 85% of uninvolved limb) (FIGURES 10 and 11)
• Static single-leg vertical jump test: height 85% of uninvolved dominant
limb or 90% of uninvolved nondominant limb (average of 3 trials)
• Single-leg broad jump test: single-leg hop for distance 85% to 90% of
uninvolved limb (average of 3 trials)
• Single-leg triple jump test: 3 consecutive hops for total distance 85% to
90% of uninvolved limb (average of 3 trials)
• Single-leg speed hop test: 10-m single-leg hop for speed, where time to
cover distance is 90% of uninvolved limb (average over 3 trials)
• Running single-leg vertical jump test: height of 85% to 90% of uninvolved dominant limb or 90% to 95% of uninvolved nondominant limb
(average of 3 trials)
Neuromuscular/Proprioceptive Awareness Criteria
• Landing Error Scoring System18: score of 0 to 2
• Single-leg forward hop test: kinematics similar to that of uninvolved
limb (balanced landing; none or minor valgus knee moment; landing
foot fixed; attenuation of forces through foot, ankle, knee, hip, and lumbar spine; proper joint angles at each joint upon landing)
• Single-leg lateral hop test: same criteria as for single-leg forward hop
test, following a lateral hop jump and landing (to the same side as the
limb used)
• Single-leg fatigued hop test4: single-leg hop test performed following 1
set of knee extension and 1 set of isotonic flexion (50% of 1-repetition
maximum of each exercise) exercises to fatigue and a 1-minute rest
before beginning test
• Single-leg perturbation test: single-leg minisquat position held for 20
seconds with manual perturbation about the shoulders and hips, maintaining position without contralateral foot touchdown and holding same
depth (15°, 30°, 45° knee flexion) throughout the test
Basketball-Specific Criteria
• Successful execution of high-intensity basketball-specific drills
in phase 3
• Repeat hop drills (hop turns at 90° and 180° with basketball pass and
catch drills) (ONLINE VIDEOS 8 and 9)
• Footwork agility drills (stutter step and lateral crossover step ladder
drills) (ONLINE VIDEOS 10 and 11)
• Reactive drills (crab dribble, defensive dribble, close-out drills)
(FIGURES 12 through 14, ONLINE VIDEOS 13 through 15)
• Basketball agility drills (zigzag, sprint to backpedal, box, star, and ball
chase drills) (FIGURES 16 through 20, ONLINE VIDEOS 16 through 19)
• Contact drills (gauntlet drill, low-post drill, leap-contact double-leg,
leap-contact single-leg drills) (FIGURE 21, ONLINE VIDEOS 20 through
22)
Cardiovascular and Psychological Criteria
• Cardiovascular capacity test12
• Psychological readiness evaluation (by team psychologist and medical
staff)6
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