ISO KINETIC KINE : تحقیق و بررسی

محمد نوابی


Original article

Return to sports after ACL reconstruction:

a new functional test protocol

G.N. Bisciotti1

A. Quaglia2

A. Belli3

G. Carimati2

P. Volpi2,3

 

 

۱  Qatar Orthopaedic and Sport Medicine Hospital, FI- FA Center of Excellence, Doha

۲ Department of knee Orthopedic and Sports Trauma- tology Unit, Humanitas Research Hospital. Roz- zano, Italy

۳   FC Internazionale Medical Staff. Milano, Italy

 

 

Corresponding author:

 

 

 

 

 

 

 

 

Summary

 

B a c k g r o u n d :  I n  l i t e r a t u r e ,  t h e r e  a r e  l a c k  o f studies proposing clear and rationally designed t e s t  b a t t e r y  t o  b e  p e r f o r m e d  a f t e r  a n  A C L reconstruction,

Methods: From 2006 to 2015, 80 football players were subjected, after ACL reconstruction, to a newly conceived test battery analyzing:

i.   Isometric and isokinetic force production ii.  The different phases during the jump.

iii. The correct control of the landing phase after jump.

iv. The control of valgus during   landing after jump  and cutting movements

Results: The isokinetic and isometric test do not show any significant relationship with the another test. The laboratory test as well the field test showed them a significant correlation. Conclusions: The results showed that a normal force production during the laboratory does not

Introduction

The anterior cruciate ligament (ACL) injury represents the most frequent ligament damage of the knee joint i n  a t h l e t e s  r e p r e s e n t i n g  a b o u t  ۵ ۰ %  o f  a l l  k n e e lesions1,2. The most part of the ACL injuries is caused by non-contact trauma, i.e during movements in which the ACL is submitted to an excessive mechani- cal stress3. In football, the incidence of ACL injuries in football is equal to 0.063 events per 1.000 hours of exposure time4. About 90% of patients with an ACL lesion undergo a reconstructive surgery and for many of them, the aspiration is to return at the same pre- injury sport sports level. Unfortunately, some studies show that the positive outcome is lower if compared to the expectations. Ardern et al.5  show that the return to sports (RTS) or return to play (RTP) 12 months after ACL reconstruction (ACLR) is within a f a i r l y  w i d e  r a n g e ,  b e t w e e n  ۳ ۳ %  a n d  ۹ ۲ % .  T h i s breadth range leaves many questions and doubts about the safety of reaching a positive outcome. In addition, other authors report a relatively high risk, between 4% and 13%, concerning recurrence or secondary injury6-12.

The higher incidence of re-injuries has been recorded in the first two years after surgery8.

T h i s d a t a s h o u l d m a k e u s r e f l e c t o n t h r e e m a i n factors that are listed below:

i.    The adequacy of rehabilitation programs;

ii.   The need of longer recovery period   before RTS

and RTP for high-level athletes;

iii.  The inadequacy of the functional tests used in the

decision-making for RTS and RTP.

The aim of this article is to propose a new functional

t e s t  b a t t e r y  t h a t  i s  p a r t i c u l a r l y  a b l e  t o  p r o v i d e

elements for RTS and RTP decision making. As

r e q u i r e d  o u r  r e s e a r c h  w a s  e t h i c a l l y  c o n d u c t e d

according to international standards13.

Material and methods

Subjects

During the period between 2006-2015, the functional

guarantee an equally satisfactory production of

force during the field test.

Study design: Case series (Level III).

KEY WORDS: ACL, arthroscopic reconstruction, foot- ball, functional evaluation, rehabilitation.

tests battery described in this paper was adminis-

tered to 80 men football players (whose age, height,

a n d w e i g h t w e r e r e s p e c t i v e l y 2 4 . 4 3 ± ۶ . ۰ ۵ y e a r s ,

۱۷۸٫۰۶±۴٫۲۰ cm and 78.18±۴٫۱ kg) after ACLR. All

the subjects underwent arthroscopic reconstruction

following ACL injury. The type of reconstruction and

Muscles, Ligaments and Tendons Journal 2016;6 (4):499-509                                                                                                                   ۴۹۹

Table I. Type of reconstruction and  sports activity performed by  the considered subjects.
Graft type                    N° cases                Professional football players (%)           Amateur football players (%)
Patellar tendon            ۴۵                            ۱۵٫۶                                                              ۸۴٫۴

Hamstring                     ۳۵                            ۹۱٫۴                                                              ۸٫۶

 

Total                             ۸۰

the sports activity level of the considered subjects are

shown in Table I. All the subjects were informed

about the aims of the research and the connected

risks and all of them gave a written consensus.

 

Protocol

 

During the rehabilitation period (165.93±۱۶٫۷۳ days) all the subjects performed a battery of test consisting of 8 different trials i.e:

i.    Isometric yo-yo test (IYYT);

ii.   Isokinetic test (IT);

iii.  Synchro plates test (SPT);

iv.  Modified triple leg jumping test (MTLJT);

v.   Modified side-step cutting test (MSSCT);

vi.  Sprint braking test (SBT);

vii. Illinois agility test (IAT);

viii. Modified Illinois Agility Test (IATm).

 

Isometric yo-yo test (IYYT)

D u r i n g  I Y Y T  ( F i g .  ۱ ) ,  t h e  s u b j e c t  p e r f o r m s  a n

isometric push contemporary with both legs over a

double synchronized force platform (Thesis System,

Globus Italy. Reliability of the measure: 0.5 Kg; error

device: <1%; sample rate 1000 Hz; sample depth 140

bit). During the push, the subject was bound to the

Yo-Yo machine that offered a supramaximal resis-

tance thereby making isometric push. The duration of

the isometric push was 5’ and the knee angle during

the push was standardized at 110°. During the push,

the above mentioned synchronized force platforms

simultaneously detected the strength signal for each

leg. Three trials were performed and it was used in

calculating the average. The data were normalized in

r e l a t i o n s h i p t o t h e p e r c e n t a g e o f s u b j e c t ’ s b o d y

weight (BW).

 

Isokinetic test (IT)

The isokinetic protocol test adopted was structured

as follows:

i.    Quadriceps   contraction performed at 60°/sec

(QC 60°)

ii.   Hamstring   positive contraction performed at 60°

(HC 60°)

The data were normalized in relationship to the sub-

ject BW. The recorded data were compared with ref-

e r e n c e d a t a c o m i n g f r o m o u r d a t a b a s e a n d a r e

shown in Table II.

 

Figure 1. During the IYYT the subject is bound to the equipment via the  yo-yo ca- ble   which offers a supra- maximal resistance making i s o m e t r i c t h e p u s h m o v e – m e n t .  T w o  s y n c h r o n i z e d force platforms (Thesis Sys- tem, Globus Italy. Reliability of the measure: 0.5 Kg; er- ror of device: <1%; sample rate 1000 Hz; sample depth

۱۴۰ bit) record the isometric s t r e n g t h v a l u e d u r i n g t h e push performed by the sub- ject.

Table II. Reference value considered during IT.
Type of test           Reference value                       Maximum % difference between injured and non-injured leg
QC 60°                   ۳٫۲۶ ±۰٫۴۷ (N.m-1 .kg-1)             ۸٫۶۴ ± ۹٫۱

HC 60°                    ۱٫۷۵ ±۰٫۲۸ (N.m-1 .kg-1)             ۵٫۱۲ ±۰٫۲۵

Synchro Plates Test (SPT)

During SPT14 the subject is on a double synchronized

force platform (Thesis System, Globus Italy. Reliabili-

ty of the measure: 0.5 Kg; error of device: <1%; sam-

p l e  r a t e  ۱ ۰ ۰ ۰  H z ;  s a m p l e  d e p t h  ۱ ۴ ۰  b i t )  a n d

performed a countermovement jump (CMJ) with 90°

flexion knee angle. During the landing phase, the

subject stopped the movement another time at 90°

flexion knee angle (Fig. 2). The force platforms, after

r e c o r d i n g   s i m u l t a n e o u s l y   t h e   s t r e n g t h   s i g n a l ,

automatically calculated and compared the two force

signals recorded in four different phases, specifically:

–    ۱st phase or negative over-stretching phase

–    ۲nd phase or maximal negative strength phase

–    ۳rd phase or maximal positive strength phase

–    ۴th phase or landing phase

During the above-listed four phases, corresponding to

different muscular activation patterns, the following

parameters were calculated:

i.    The maximal negative acceleration value calculat-

ed during the stretching phase (MAneg recorded

during the 1st phase)

ii.   The maximal negative force value (MFecc record-

ed during the 2nd phase)

iii.  The maximal positive force value (MFcon record-

ed during the 3rd  phase)

iv.  The maximal landing force (or impact force) value

(MFimp recorded during the 4th phase)

The biomechanical interpretation of the above para-

meters recorded during the different phases can be

briefly summarized as follows:

i.    MAneg (Fig. 3) and MFecc (Fig. 4): those are

specific parameters regarding the muscle exten-

sor apparatus negative phase. The reference val-

ues must be less than (injured limb versus healthy

limb) 15%14.

ii.   MFcon: during this phase, the elastic energy

stored during the negative phase is transformed

into mechanical work. The mechanical work gen-

erated from the stored elastic energy, enhance

the force produced by the muscle contractile com-

ponent during the positive phase. Therefore, the

value recorded during this phase represents the

extensor muscles elastic behavior. The reference

values must be less than (injured limb versus

healthy limb) 15%14 (Fig. 5).

iii.  MFimp: this value is recorded during the impact

phase (i.e. the phase during which the subject

lands over the force platform at the end of the fly

phase) (Fig. 6). During this phase, it is evident the

protective behavior for the safeguard of the in-

jured limb. If the injured   limb has not yet fully

reached its functional and proprioceptive capaci-

ties, in this phase is present an important differ-

ence, in comparison to the uninjured limb, into the

force signal recorded by the force platform15. The

reference values must be less than (injured limb

versus healthy limb) 10% 14.

 

Figure 2. The  SPT protocol  provides that the subject performs a CMJ (90° knee flexion angle) and stops the landing phase with a knee angle another time equal to 90°. Two synchronized force platforms (Thesis System, Globus Italy. Re- liability of the measure: 0.5 Kg; error of device: <1%; sample rate 1000 Hz; sample depth 140 bit) record the force sig- nal during the jump movement.

Muscles, Ligaments and Tendons Journal 2016;6 (4):499-509                                                                                                                   ۵۰۱

Figure 3. The negative acceleration peak (MAneg) represents the overstretching capabilities of the extensor muscles. (_ uninjured limb  _ injured li

Figure 4. The maximum force applied during the negative phase (MFecc) represents the maximum negative strength ex- pressed by the extensor muscles immediately before the inversion of the movement (i.e immediately before the positive phase). (_ uninjured limb  _ injured limb).

For more details concerning the SPT protocol and the data interpretation, we refer the reader to consult the specific article14,15.

Modified triple leg jumping test (MTLJT) and modified sidestep cutting test (MSSCT)

The protocol for both tests provide first, a knee Q-

Figure 5. The MFcon value represents the capacity of storage and reuse of elastic energy by the extensors muscle-ten- don unit. (_ uninjured limb  _ injured lim

Figure 6. The maximum impact force value during the landing phase (MFimp) highlights the protective mechanisms used by the subject  (_ uninjured limb  _ injured limb).

angle static measurement, classically carried out by measuring the angle formed by a line joining the antero superior iliac spine (ASIS) and the patella center (i.e.

the quadriceps vector force) and with a line joining the center of the patella with the anterior tibial tuberosity (i.e. the patella anatomical axis). After the Q-angle

measurement, the operator places 3 markers over the subject’s lower limb, the first is placed on the line connecting the ASIS to the center of the patella, about

۲۰ cm above the patella, the second at the center of the patella and the third at anterior tibial tuberosity level. D u r i n g  t h e  M T L J T  t e s t ,  t h e  s u b j e c t  i s  a s k e d  t o perform three monopodalic jumps on frontal plane (Fig. 7), first with his uninjured leg and then with the injured leg. During the test, a camera is placed per- pendicularly to the subject, in order to avoid parallax errors, it records the entire sequence. A dedicated software measures the maximum value of the dynam- ic Q-angle during the contact with the ground.

During the MSSCT test (Fig. 8) the subject is asked, after a run of 5 meters, to touch a skittle 50 cm tall and then make a change of direction at 90° and run at maximum speed to a second skittle, situated 5 meters away. As in the previous test a camera is again placed perpendicularly to the first skittle that records the test. The same software used for the M T L J m e a s u r e s t h e d y n a m i c Q – a n g l e m a x i m u m value during the change of direction carried out in correspondence of the first skittle. The dynamic Q- angle reference value for the injured limb during both the MTLJT and MSSCT must not exceed the 20% of the value of the static Q- angle previously measured.

Figure 7. Dynamic Q-an- gle measurement during MTLJT.

Figure 8. Dynamic Q-an- gle measurement during MSSCT.

Sprint Braking Test

The Sprint Braking Test (SBT)15  protocol provides a

preliminary test consisting a maximal sprint for 30

meters. Once the sprint test is performed the subject

is asked to make a sprint over the same distance at

۹۰% of the maximum speed recorded during the

preliminary test and to stop at the level of a skittle

placed at a determined distance from the end of the

sprint. The protocol provides for three tests, the first

of which the stop-skittle is placed at 8 meters, and

the second and the third respectively at 6 and 4

meters from the end of the sprint. The purpose of the

S B T  i s  t o  q u a n t i f y  i n  a n  o b j e c t i v e  m a n n e r  t h e

effectiveness of the contraction of the flexor muscles

during the braking phase. In fact, during the arrest

time, the subject must dissipate the kinetic energy (C)

taken during the sprint by a certain value (dependent

on his mass and the speed reached) to zero. Know-

ing the C value and the stopping distance (s) is possi-

ble to calculate the value of the negative power1  ex-

pressed by the subject during the braking phase.

It is, therefore, possible to calculate in indirect man-

ner the effectiveness of the flexor muscles co-con-

traction through the following formula:

P (W) = (0.5 M · V2) /Tf                                         (۱)

in which P is the negative power expressed in W,  M

i s  t h e  s u b j e c t ’ s  m a s s ,  V  i s  t h e  a v e r a g e  s p e e d

reached during the sprint and Tf is the braking time,

the   time taken to reach V0 (zero speed, the full

stop).

Knowing that Tf is equal to: V2. s/a                          (۲)

in which s is the braking and a the acceleration, and

knowing that the a value is equal to: V2 /2.s (3) in which

V2 is the square of the speed reached by the athlete

during the sprint,

Replacing the a value derived from (3) to (2) and

replacing to (1) the Tf value derived from (2), it is

possible to calculate the P value, i.e. the negative

power expressed during the contraction of the flexor

muscles into the braked phase. An electronic spread-

sheet specifically conceived, allowed the calculation.

The reference minimum value to reach into the test

was fixed in 20 W/kg-1.

Illinois Agility test (IAT) and modified Illinois Agility

Test (IATm).

In the Illinois Agility Test (IAT)16, 17 the subject must

perform at maximum speed the entire path according

to the scheme shown in Figure 9. The start is freely

determined by the athlete. The chronometric result

represents the final score of the test (Tab. III). The

Figure 9. IAT and IATm scheme. The test length  – i.e the distance between the start point and the stop point – is, in both cases,  ۱۰ meters, while the width of the test area is 5 meters.

۱ The definition of “negative” power is justified by the fact that represents a power used to decelerate a mass and not to accelerate as in case of “positive” power.

modified Illinois Agility Test (IATm)18  provides the same protocol of IAT but performed with the ball. Also, in this case, the start is freely determined by the athlete and the chronometric result represents the fi- nal score of the test (Tab. IV).

The timing of administration of the battery of function- al evaluation

The progression of the battery is supported by a ra-

tional application mainly based on a proper balance

between the need to monitor the progress of the pa-

tient and the need to safeguard the biological integrity

of the neo-ligament.

The results of functional tests performed will define the

entire rehabilitation process towards a “goal- target pro-

tocol”. In Table V the various tests mentioned above

are presented in their temporal sequence of administra-

tion depending upon the rehabilitation period.

Statistics

The homogeneity of the sample regarding age and an- thropometric values was tested by a non-parametric Kolmogorov-Smirnov test. The   force value   recorded during IT and SPT as well as the power recorded dur- ing SPT was standardized on the basis of subjects BW. The relationship between all  recorded value was calcu- lated by a Spearman’s rank correlation coefficient. Sta- tistical significance was set at p<0.05.

Results

IYYT recorded value in the injured limb was 46.32

±۷٫۰۹ of the BW.

IT recorded value in the injured limb were 2.36 ± ۰٫۵۱

and 1.15± ۰٫۳۱ N.m-1  .kg-1  respectively, for QC 60°

and HC 60° test.

Table III. IAT reference values.SPT recorded values in the injured limb were 3.52 ±

۲٫۱۲ m.s-2  for MAneg  test;   ۹۷٫۸۱ ± ۱۵٫۱۳% BW for

MFecc test; 124.10 ± ۱۳٫۲۰% BW for MFcon  test and

۲۱۳٫۱۲ ± ۴۲٫۳ % BW for MFimp.

The dynamic Q-angle value measured during MTLJT

was 16.21 ± ۲٫۳۱% greater than the static Q- angle

value previously measured.

The dynamic Q-angle value measured during MSSCT

was 17.11 ± ۱٫۹۸% greater than the static Q- angle

value previously measured.

SBT recorded values was 22.51±۲٫۳۱ W.kg-1.

The IAT recorded value was 17.11 ± ۱٫۶۲ sec.

The IATm recorded value was 18.91 ± ۲٫۰۳ sec.

The statistic significance of the relationship of the

considered values are shown in Table VI.

 

 

Discussion

 

Many studies noted a change in the movements n e u r o m u s c u l a r  p a t t e r n  a t  t h e  i n j u r e d  l i m b  l e v e l compared to the contralateral in male and female subjects underwent ACLR19-21.

Rating    Lap result  (sec)
Excellent < 15.2

Good       ۱۶٫۱-۱۵٫۲

Medium   ۱۸٫۱-۱۶٫۲

Insufficient              ۱۸٫۳-۱۸٫۲

Very insufficient      > 18.3

 

 

Table IV. IATm reference values.

Rating    Lap result  (sec)
Excellent < 16.2

Good       ۱۷٫۱-۱۶٫۲

Medium   ۱۹٫۱-۱۷٫۲

Insufficient              ۱۹٫۳-۱۹٫۲

Very insufficient      > 19.3

Table V. The various tests above placed in a logical temporal sequence of execution depending on the rehabilita-

tion period. The sig (+) indicates the period in which the execution of the test is advisable. In the last column it is indicated the period during which the test was performed in the considered series.

Type of test    ۶۰ days     ۹۰ days    ۱۲۰ days    ۱۵۰ days    ۱۸۰ days     Period in which the test was performed
IYYT                +                +                +                                                           ۹۰٫۷±۱۷٫۱ days post-surgery

IT                                                          +                 +                  +                   ۱۶۸٫۶±۱۲٫۲ days post-sugery SPT                                                                           +                  +                   ۱۶۳٫۶±۸٫۲ days post-surgery MSSCT                                                                     +                  +                   ۱۶۸٫۶±۶٫۳ days post-surgery MTLJT                                                                                           +                   ۱۸۱٫۵±۷٫۲ days post-surgery SBT                                                                           +                  +                   ۱۶۵٫۳±۱۱٫۸ days post-surgery IAT                                                                            +                  +                   ۱۷۰٫۶±۹٫۸ days post-surgery IATm                                                                         +                  +                   ۱۶۹٫۶±۸٫۵ days post-surgery

The alteration of the pattern movement is particularly evident during the execution of movements such as the monopodalic jump (single leg jumping), jumping with both feet in the sagittal plane (sagittal double leg jumping), lateral jumps, changes of direction (side- step cutting) and run19,22-24.  This alteration would remain for a period of time between 6 and 24 months, even in the case where the athlete has fully resumed the sporting activity19. The most significant changes are an increase in the valgus dynamic especially in landing phase after jump, an asymmetry of the two lower limbs in the initial moment of contact with the ground, instability in monopodalic movements, and a rotation of the hips in the opposite direction of the injured limb25.

It is important to point out  that the mechanical stress of the ACL increases dramatically in the condition of valgus, especially if this situation is associated with internal rotation, while the valgus associated with e x t e r n a l   r o t a t i o n ,   e v e n   i f   p r e s u p p o s e s   l e s s m e c h a n i c a l   s t r e s s ,   c r e a t e s   t h e   c o n d i t i o n   f o r impingement of the ACL26.

The force vector generated by the contraction of the quadriceps muscle, if not properly counterbalanced by the carrier generated in the opposite direction from the contraction of the flexor muscles of the thigh, can cause an anterior sliding of the tibia that can damage the anatomical integrity of the neo-ligament27. In other words, the action of co-contraction of the flexor m u s c l e s  i s  e s s e n t i a l  f o r  t h e  p r o t e c t i o n  o f  n e o – ligament in order to counteract excessive forces t e n d i n g t o p r o d u c e a n t e r i o r t i b i a l s l i d i n g b y t h e extensor musculature28. For all these reasons, it is clear the need to dispose of a battery of tests able to d e t e c t  t h e  i m p a i r m e n t  a n d  t h e  p r o g r e s s  o f  a rehabilitation program29.

For this reason, we propose a battery of tests analy- zing:

  1. i. A correct force production in isometric condition by the extensor muscles of the lower limbs and by the hip extensors muscles by of the injured and healthy limb during the early phase of rehabilita- tion plan (YYT).
  2. ii. A correct force production during isokinetic condi- tion in a more advanced phase of rehabilitation plan (IT).

iii.  The correct activation of the extensor, flexor mus- cles and the correct control of the landing phase during bipodalic ballistic movement (SPT).

  1. iv. The correct control of dynamic valgus (MTLJT

and MSSCT).

  1. v. The effectiveness of the contraction of flexor mus-

cle during a braking movement into the control of

the anterior tibial shift (SBT).

  1. vi. The correct control of valgus and anterior tibial

shift during cutting movement performed at high

run speed without and with ball (IAT and IATm).

Each type of tests will be inserted within a time

sequence of the administration taking into account

the biological times of integration of the neo-ligament.

Although it must be remembered that the studies in

t h e  l i t e r a t u r e  a b o u t  t h e  s o – c a l l e d  p r o c e s s  o f

ligamentization are, to date, rather far from reaching a consensus about it30-32.

It is important to emphasize that this sequence of tests is based on the principle of “goal-target proto- col”. In other words, the various steps of the rehabili- tation plan are rather based on the achievement of a well-defined functional outcome rather than on the principle of “time-frame protocol”.

The loss of correlation between YYT and the other strength laboratory test (IT and SPT) may explain the difference of the activation pattern between isometric contraction and positive work contraction33. In any case, YYK allows the advantage to be able to test the subject into the early phase of the rehabilitation (starting from 60 days). Furthermore, this test is per- formed in the closed kinetic chain and therefore the mechanical stress at neo-ligament level is minimal. Indeed, in the literature, there is still present a contro- versy concerning the early introduction of exercises and test in open kinetic chain as part of rehabilitation after ACLR34-36.

The correlation that the different parameters recorded during SPT (i.e. MAecc, MFecc, MFconc and MFimp) shows that the jump movement patterns of activation are strongly interconnected. Therefore, a deficiency of one of these parameters may compromise the en- tire motion pattern15,37. Furthermore, the correlation between the parameters recorded during IT (i.e. QC and HC) and the   different parameters recorded dur- ing SPT (i.e.   MAecc, MFecc, MFconc and MFimp) show the influence of isokinetic force and the explosive force applied during a ballistic movement38.

The correlation between MSSCT and MTLJT shows how the movement control of dynamic valgus during the landing phase after a jump (MSSCT) and during a cutting movement (MTLJT) are strongly interrelated. The correlation between SBT, IAT and IATm show the specificity of this test for the assessment of the control of tibial anterior shift during a run in which is required an important deceleration phase. Indeed, during the deceleration phase, the hamstring contrac- tion is essential into the control of tibial anterior shift and, therefore, for the neo-ligament protection18,28. Finally, the loss of correlation between the so-called laboratory tests (IYYT, IT and SPT) and field tests (MSSCT, MTLJT, SBT, IAT and IATm) shows how the force production patterns are highly “velocity-de- pendent”۳۹,۴۰٫ In other words, a satisfactory force pro- duction during the laboratory tests does not guaran- tee an equally satisfactory production of force during the field test.

Conclusions

It is important to underline that, concerning ACLR, the most important variable is represented by the va- lidity of the surgical technique performed and by the accuracy with which the latter is made. In addition, we think that an essential part of the positive out- come after surgery is a proper rehabilitation process and an equally suitable strategy of functional assess-

ment, based on a solid scientific rationale. The reha- bilitation following ACLR should not be trivialized, and it is a milestone for a full recovery both from an anatomical and functional point of view.

It is noted that the rehabilitation process can be con- sidered, in fact, finished with anatomical healing

for sedentary patients, but this is not true for sports subjects. Indeed, in sports, subjects is essential to the resumption of full functionality, this aspect is as much important as higher is the performance level of the subject.

The battery of functional tests described in this study is certainly an ambitious and innovative

proposal, an alternative to those normally used. This requires the use of highly specific structures, materi- als and technical skills which represent, in our opin- ion, the discriminating variables between the main- stream and excellence rehabilitation programs.

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