Rehabilitation and nutrition protocols for optimising return to play from traditional ACL reconstruction in elite rugby union players: A case study

Review perspective on advanced nutrachemicals and anterior cruciate ligament rehabilitation

Anterior cruciate ligament (ACL) injuries are prevalent among athletes, necessitating surgical intervention followed by comprehensive rehabilitation. Recently, the integration of nutraceuticals - bioactive compounds from food sources - into rehabilitation protocols has shown promise in enhancing recovery outcomes. This review explores the potential benefits of various nutraceuticals, including omega-3 fatty acids, collagen supplements, vitamin D, glucosamine and chondroitin, curcumin, and branched-chain amino acids (BCAAs), in ACL rehabilitation. These nutraceuticals offer anti-inflammatory properties, support tissue repair, and improve joint and muscle health, which are critical during the rehabilitation process. Despite encouraging preclinical findings, there is a need for robust clinical trials to confirm their efficacy and establish optimal dosages and formulations. Personalized nutrition plans and interdisciplinary collaboration among healthcare providers are essential for optimizing patient care. This perspective underscores the potential of advanced nutraceuticals to revolutionize ACL rehabilitation, paving the way for faster and more effective recovery pathways.

Saturated fatty acids negatively affect musculoskeletal tissues in vitro and in vivo

Fish oils rank among the world's most popular nutritional supplements and are purported to have numerous health benefits. Previous work suggested that fish oils increase collagen production; however, the effect of fish oils on musculoskeletal health is poorly understood. Further, the divergent effects of omega-3 (Ω3FA) and saturated fatty acids (SFA) remains poorly understood. We tested the effects of Ω3FA and SFAs on in vitro-engineered human ligament (EHL) function. EHLs were treated with bovine serum albumin (BSA)-conjugated eicosapentaenoic acid (EPA, 20:5(n-3)), palmitic acid (PA, 16:0), or a BSA control for 6 days. EPA did not significantly alter, whereas PA significantly decreased EHL function and collagen content. To determine whether this was an in vitro artifact, mice were fed a control or high-lard diet for 14 weeks and musculoskeletal mass, insulin sensitivity, and the collagen content, and mechanics of tendon and bone were determined. Body weight was 40 % higher on a HFD, but muscle, tendon, and bone mass did not keep up with body weight resulting in relative losses in muscle mass, tendon, and bone collagen, as well as mechanical properties. Importantly, we show that PA acutely decreases collagen synthesis in vitro to a similar extent as the decrease in collagen content with chronic treatment. These data suggest that Ω3FAs have a limited effect on EHLs, whereas SFA exert a negative effect on collagen synthesis resulting in smaller and weaker musculoskeletal tissues both in vitro and in vivo.

Greater Post-Operative Nutrition Risks Identified in Pediatric and Adolescent Patients after Anterior Cruciate Ligament Reconstruction Regardless of Age and Sex

Systematic detection of risky nutrition behaviors after sports surgery may better promote healing for return-to-sport. The purpose of this study was to assess nutritional behavior differences between patients following anterior cruciate ligament reconstruction (ACLR) and following other lower-extremity orthopedic surgeries. One pediatric sports medicine center was reviewed for a custom Sports Nutrition Assessment for Consultation, which investigates nutrition-related risk factors for youth athletes at their first post-operative visit. Patients reported "Yes" or "No" to eight questions, after which they were offered a nutrition consultation for any response indicating risk. A total of 243 post-ACLR and 242 non-ACLR patients were reviewed. The post-ACLR patients more often reported a change in appetite (p = 0.021), recent weight changes (p = 0.011), a desire to better understand nutrition (p = 0.004), and recommendations to change their body composition (p = 0.032). More post-ACLR patients were identified for a nutrition consultation (p = 0.002), though an equal percentage accepted the consultation between groups. Age and sex were not determined to be significant confounders after matched sub-analysis. The post-ACLR patients more often reported nutrition risks, specifically weight-related issues, regardless of age or sex. Sports surgeons should regularly inquire about nutrition-related concerns with patients and refer to sports dietitians for recovery nutrition support as needed, particularly after ACLR.

Regenerative Anterior Cruciate Ligament Healing in Youth and Adolescent Athletes: The Emerging Age of Recovery Science

Anterior cruciate ligament (ACL) injuries mainly arise from non-contact mechanisms during sport performance, with most injuries occurring among youth or adolescent-age athletes, particularly females. The growing popularity of elite-level sport training has increased the total volume, intensity and frequency of exercise and competition loading to levels that may exceed natural healing capacity. Growing evidence suggests that the prevailing mechanism that leads to non-contact ACL injury from sudden mechanical fatigue failure may be accumulated microtrauma. Given the consequences of primary ACL injury on the future health and quality of life of youth and adolescent athletes, the objective of this review is to identify key "recovery science" factors that can help prevent these injuries. Recovery science is any aspect of sports training (type, volume, intensity, frequency), nutrition, and sleep/rest or other therapeutic modalities that may prevent the accumulated microtrauma that precedes non-contact ACL injury from sudden mechanical fatigue failure. This review discusses ACL injury epidemiology, current surgical efficacy, the native ACL vascular network, regional ACL histological complexities such as the entheses and crimp patterns, extracellular matrix remodeling, the concept of causal histogenesis, exercise dosage and ligament metabolism, central nervous system reorganization post-ACL rupture, homeostasis regulation, nutrition, sleep and the autonomic nervous system. Based on this information, now may be a good time to re-think primary ACL injury prevention strategies with greater use of modified sport training, improved active recovery that includes well-planned nutrition, and healthy sleep patterns. The scientific rationale behind the efficacy of regenerative orthobiologics and concomitant therapies for primary ACL injury prevention in youth and adolescent athletes are also discussed.

Perioperative Management in the Collegiate Athlete: An Integrated Approach

Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.

Characteristics of return to running programs following an anterior cruciate ligament reconstruction: A scoping review of 64 studies with clinical perspectives

OBJECTIVE

To (1) describe return to running (RTR) programs used during rehabilitation after anterior cruciate ligament reconstruction (ACLR); and (2) provide clinical guidelines for RTR program after ACLR.

DESIGN

Scoping review.

LITERATURE SEARCH

We searched the MEDLINE (Pubmed), EMBASE, Web of Science and PEDro databases.

STUDY SELECTION CRITERIA

We included randomized controlled trial (RCT), cases series, meta-analyses, both scoping and systematic reviews including a rehabilitation program after ACLR with a specific RTR program. A "Running program checklist" (RPC) was elaborated based on the Template for Intervention Description and Replication (TIDieR), and on the Consensus on Exercise Reporting Template (CERT) checklist.

DATA SYNTHESIS

The percentage and number of studies specifying each of the running program checklist items in their RTR program were reported. Number of items reported in each study and specific analysis item-by-item were also proposed.

RESULTS

The "When (2)" item was the most frequently found (92.19%) and, conversely, the "Who (1)" item appeared only in four studies (6.2%). One-third of the studies presented only one item of the RPC, and 48 of the 64 articles discussed less than three items. Two studies described in detail their RTR program by reporting 8 and 9 items out of the 10, respectively. No study presented 10 of the PRC items.

CONCLUSION

There is a serious lack of information concerning RTR program following ACLR in the literature and further studies are needed to establish a program based on the best evidence.

“Food First but Not Always Food Only”: Recommendations for Using Dietary Supplements in Sport

The term “food first” has been widely accepted as the preferred strategy within sport nutrition, although there is no agreed definition of this and often limited consideration of the implications. We propose that food first should mean “where practically possible, nutrient provision should come from whole foods and drinks rather than from isolated food components or dietary supplements.” There are many reasons to commend a food first strategy, including the risk of supplement contamination resulting in anti-doping violations. However, a few supplements can enhance health and/or performance, and therefore a food only approach could be inappropriate. We propose six reasons why a food only approach may not always be optimal for athletes: (a) some nutrients are difficult to obtain in sufficient quantities in the diet, or may require excessive energy intake and/or consumption of other nutrients; (b) some nutrients are abundant only in foods athletes do not eat/like; (c) the nutrient content of some foods with established ergogenic benefits is highly variable; (d) concentrated doses of some nutrients are required to correct deficiencies and/or promote immune tolerance; (e) some foods may be difficult to consume immediately before, during or immediately after exercise; and (f) tested supplements could help where there are concerns about food hygiene or contamination. In these situations, it is acceptable for the athlete to consider sports supplements providing that a comprehensive risk minimization strategy is implemented. As a consequence, it is important to stress that the correct terminology should be “food first but not always food only.”

Nutritional Considerations for Injury Prevention and Recovery in Combat Sports

Sports participation is not without risk, and most athletes incur at least one injury throughout their careers. Combat sports are popular all around the world, and about one-third of their injuries result in more than 7 days of absence from competition or training. The most frequently injured body regions are the head and neck, followed by the upper and lower limbs, while the most common tissue types injured are superficial tissues and skin, followed by ligaments and joint capsules. Nutrition has significant implications for injury prevention and enhancement of the recovery process due to its effect on the overall physical and psychological well-being of the athlete and improving tissue healing. In particular, amino acid and protein intake, antioxidants, creatine, and omega-3 are given special attention due to their therapeutic roles in preventing muscle loss and anabolic resistance as well as promoting injury healing. The purpose of this review is to present the roles of various nutritional strategies in reducing the risk of injury and improving the treatment and rehabilitation process in combat sports. In this respect, nutritional considerations for muscle, joint, and bone injuries as well as sports-related concussions are presented. The injury risk associated with rapid weight loss is also discussed. Finally, preoperative nutrition and nutritional considerations for returning to a sport after rehabilitation are addressed.

Unilateral Maximal Isometric Hex Bar Pull Test: Within-Session Reliability and Lower Body Force Production in Male and Female Freeski Athletes

The aim of the study was to (1) assess the within-session reliability of a unilateral isometric hex bar pull (UIHBP) maximal voluntary contraction (MVC) test and, (2) determine unilateral isometric absolute peak force (PFabs) and relative peak force (PF) values in freeski athletes. Twenty-one male and eight female academy to national team freeskiers performed the novel UIHBP MVC task on a force plate and PFabs and relative PF were assessed (1000 Hz). Within-session measures of PFabs offered high reliability on left and right limbs for males (ICC = 0.91-0.94, CV = 2.6-2.2%) and females (ICC = 0.94-0.94, CV = 1.4-1.6%), while relative PF measures showed good to high reliability in both left and right limbs for males (ICC = 0.8-0.84, CV = 2.6-2.2%) and females (ICC = 0.92-0.90, CV = 1.4-1.7%). We observed significantly lower PFabs (p < 0.001) and relative PF (p < 0.001) in females compared to males. No statistical difference was found between left and right limbs in males and females in PFabs (p = 0.98) and relative PF measures (p = 0.93). The UIHBP MVC test appears to be a reliable method for assessing PFabs and relative PF in male and female freeski athletes.