Case StudiesReturn to competition after an Achilles tendon rupture using both on and off the field load monitoring as guidance: A case report of a top-level soccer player
Introduction
An Achilles tendon rupture (ATR) may dramatically influence the sporting career of an elite athlete and only 60% are reported to return to the same professional level (Amin et al., 2013, Parekh et al., 2009). ATR has been classified as a severe injury in soccer players due to the extended absence from activity/sport (median lay-off time of 169 days) (Gajhede-Knudsen, Ekstrand, Magnusson, & Maffulli, 2013).
Return to sport (RTS) is the last part of the rehabilitation process and can be very stressful both mentally and physically for an elite athlete (Ardern et al., 2016). Generally, players want to return to competition as soon as possible and this can lead to an accelerated rehabilitation with increased risk of re-injury. In order to prevent re-injury, it is recommended that an athlete should have recovered both general and specific capabilities of the sport prior to return to practice with the team. However, it is mostly stated in rehabilitation protocols that the athlete should slowly progress to full participation without any specific suggestions concerning how to progress or how to measure the changes in training load (TL). The assessment of TL is widespread in sport science and its monitoring may give guidance in progression during RTS (Hoover, VanWye, & Judge, 2016). Modern technologies as Global Positioning System (GPS) and heart rate monitors provide useful support to monitor load and its changes through the RTS period.
For the above reasons the RTS period is probably one of the most delicate rehabilitation phases where both overloading and underloading have a negative impact on the speed of recovery. Hence, having specific criteria for progression is of benefit for the athlete.
There is a lack of evidence on what to base the RTS decision after ATR in soccer players (Ardern et al., 2016, Drust et al., 2014). Deficits in strength, explosive capability (i.e. jumps), and endurance in patients with an ATR may remain for a long periods (i.e. 1–2 years) after the injury (Nilsson-Helander et al., 2010, Olsson et al., 2011). Furthermore, in elite sport other sports specific criteria may be of greater relevance in the RTS phase. It has been suggested that during the RTS phase the progression can be controlled by monitoring the TLs during activities in the field (Blanch & Gabbett, 2016).
The rehabilitation process after ATR in healthy patients or recreational sports athletes is well examined in recent literature (Brumann et al., 2014, Holm et al., 2015, Huang et al., 2015, Mark-Christensen et al., 2016), however no studies have described the RTS after ATR in elite players. The aim of the present case report is therefore to describe in detail the RTS phase after an ATR in an elite level soccer player.
Section snippets
Participant
The player was a 39-year-old (at the time of injury) defender (height 178 cm, body mass 75 kg) playing in an elite Italian soccer team (Serie-A, 615 matches and 19 seasons played in the same club, total number of Official matches played 1104). During the six weeks before ATR, the player was suffering from symptoms in the Achilles tendon region, however the symptoms were not consistent and allowed him to train and play matches without limitations. The player gave a written informed consent to
Results
The player returned to participate in an official competition (i.e. 15 min) 27 weeks after the injury with a lay-off time of 119 days. The first entire match (i.e. 90 min) was played 30 weeks after the injury. He played in 12 of the remaining 26 matches to the end of the season without suffering of any lower limb injury or pain in the Achilles tendon region.
Discussion
The present case-report showed a successful return to competitions of an elite soccer player after ATR. Despite studies having compared different rehabilitation regimes, the best program that provides a rapid return to competition with the minimal risk of re-injury and maximal performance ability is still debated (Brumann et al., 2014). In the present case-report, functional rehabilitation was preferred to immobilization and no complications were found during the rehabilitation period.
RTS is a
Conclusions
The present case-report showed the feasibility of using both clinical criteria combined with sport performance criteria to design a return to sport/performance plan for an elite soccer player. Strength and endurance ability are important criteria, however the ability to cope with the specific demands coming from the field may be considered most important. The monitoring of TLs can be useful in the decision making process.
Conflict of interest
None declared.
Funding
None declared.
Acknowledgements
The authors want to acknowledge the Club FC Internazionale, the Doctor Giorgio Panico and all the physiotherapists involved in the rehabilitation process Marco Dellacasa, Andrea Galli, Alberto Galbiati, Luigi Sessolo and Max Dellacasa.
References (42)
- et al.
Accelerated rehabilitation following Achilles tendon repair after acute rupture - development of an evidence-based treatment protocol
Injury
(2014) - et al.
Validity and reliability of GPS devices for measuring movement demands of team sports
Journal of Science and Medicine in Sport
(2010) - et al.
Accuracy and reliability of GPS devices for measurement of movement patterns in confined spaces for court-based sports
Journal of Science and Medicine in Sport
(2010) - et al.
Periodization and physical therapy: Bridging the gap between training and rehabilitation
Physical Therapy in Sport
(2016) - et al.
Rehabilitation of the operated Achilles tendon: Parameters for predicting return to activity
Journal of Foot and Ankle Surgery
(2011) - et al.
Use of an anti-gravity treadmill in the rehabilitation of the operated Achilles tendon: A pilot study
Journal of Foot and Ankle Surgery
(2011) - et al.
Performance outcomes after repair of complete Achilles tendon ruptures in national basketball association players
The American Journal of Sports Medicine
(2013) - et al.
2016 consensus statement on return to sport from the first world congress in sports physical therapy, Bern
British Journal of Sports Medicine
(2016) Applications of GPS technologies to field sports
International Journal of Sports Physiology and Performance
(2011)- et al.
Return to competitive football after major knee surgery: More questions than answers?
Journal of Sports Sciences
(2014)
Has the athlete trained enough to return to play safely? The acute-chronic workload ratio permits clinicians to quantify a player's risk of subsequent injury
British Journal of Sports Medicine
Molecular and cellular adaptation of muscle in response to exercise: Perspectives of various models
Physiological Reviews
Integrating different tracking systems in football: Multiple camera semi-automatic system, local position measurement and GPS technologies
Journal of Sports Sciences
Player tracking technology: Half-full or half-empty glass?
International Journal of Sports Physiology and Performance
Reliability of isokinetic dynamometry in assessing plantarflexion torque following Achilles tendon rupture
Foot & Ankle International
Return to play decisions - a highly important albeit unsolved issue
Journal of Sports Sciences
The heart rate monitor book
Sprint vs. interval training in football
International Journal of Sports Medicine
A new approach to monitoring exercise training
The Journal of Strength and Conditioning Research
Recurrence of Achilles tendon injuries in elite male football players is more common after early return to play: An 11-year follow-up of the UEFA champions league injury study
British Journal of Sports Medicine
Validity and reliability of GPS for measuring distance travelled in field-based team sports
Journal of Sports Sciences
Cited by (10)
Current Consensus for Rehabilitation Protocols of the Surgically Repaired Acute Mid-Substance Achilles Rupture: A Systematic Review and Recommendations From the “GAIT” Study Group
2022, Journal of Foot and Ankle SurgeryCitation Excerpt :The ability to achieve 5 × 25 repetitions is part of a protocol to return to activity, along with calf-circumference 10 cm distal to the tibial tuberosity within 5 mm to the nonoperative limb, and ankle ROM should be within 5° (15). Fanchini et al also described a detailed progression using an antigravity treadmill in a professional soccer player (34). The ability to perform a single heel raise is related to patient-reported outcome found that 49% of the patients were able to perform a single-leg heel raise at 12 weeks, with no difference between surgical or nonsurgical treatment (17).
Rehabilitation exercise program after surgical treatment of quadriceps tendon rupture: A case report
2019, Physical Therapy in SportCitation Excerpt :Although the use of the Krackow suture is technically more demanding than the two other suture types, Krackow sutures have been shown to present greater axial resistance than both the Bunnell and Kessler sutures (Ortiz et al., 2012). Early post-operative rehabilitation exercise program is of great importance in order to obtain and maintain rapid recovery and good functional outcomes (Fanchini et al., 2018). In the present case report, the patient attended a well-structured rehabilitation exercise program 5 times weekly for a period of 22 weeks.
Maximizing Return to Sports After Achilles Tendon Rupture in Athletes
2019, Foot and Ankle ClinicsCitation Excerpt :Time-based guidelines have suggested resumption of noncontact sports 16 weeks after injury and contact sports 20 weeks after injury, but these recommendations are not evidence based.14 Fanchini and colleagues18 offered a case report of an Italian professional soccer player in an effort to provide a potential protocol. Indeed, this report mainly highlights the vast difference between the resources at the disposal of a professional athlete versus almost anyone else, because the attention paid to this one athlete is likely not possible for most of the public and most amateur athletes.
Return to sport after surgical repair of the Achilles tendon
2023, British Journal of Hospital MedicineOn-field rehabilitation in football: Current knowledge, applications and future directions
2022, Frontiers in Sports and Active Living