Bottom Line Up Front (BLUF)
An elite female alpine ski racer’s return-to-sport journey after ACL reconstruction was managed through a comprehensive, individualized, milestone-driven plan designed by an interdisciplinary team. Despite returning to snow within 7 months, neuromuscular deficits and asymmetries persisted for up to 18 months. The case highlights the critical importance of continuous neuromuscular monitoring, a flexible, milestone-based rehabilitation plan, and team-based decision-making to support not just return to sport, but return to performance. Time alone is not a sufficient measure of recovery.
What Was Studied
This case study examines the RTS transition of an elite female alpine ski racer following ACL reconstruction with additional knee injuries. The authors aimed to demonstrate a real-world example of a collaborative, evidence-informed RTS process supported by an interdisciplinary team, serial neuromuscular testing, workload monitoring, and milestone-based progression rather than conventional time-based return guidelines.
What They Did
The athlete sustained a complex knee injury—ACL tear, medial meniscus tear, and lateral tibial plateau fracture—and underwent ACL reconstruction using a semitendinosus tendon autograft. The IPT constructed a 12-month Return to Sport Training Plan, designed similarly to an athletic macrocycle, broken down into six phases:
Return to Sport Plan and Implementation
1. Phased Recovery Timeline:
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Post-Surgical Phase: Focused on healing, restoring range of motion, gait normalization, and minimizing thigh muscle atrophy.
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Early Rehabilitation: Introduced basic movement patterns like squatting and lunging in controlled environments.
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Mid Rehabilitation: Increased neuromuscular load with strength work and low-impact plyometrics.
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Late Rehabilitation: Advanced to multi-plane plyometrics, change of direction drills, and higher intensity strength training.
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Physical Preparation for Return to Sport: Gradual exposure to sport-specific drills (dryland and on-snow) to rebuild capacity and confidence.
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Return to Sport Transition: Re-entry into competitive environments with continued monitoring and readiness checks.
2. Interdisciplinary Team (IPT) Composition and Roles:
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Sports Medicine/Orthopedic Surgeon: Oversaw healing and surgical considerations.
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Physiotherapy: Led tissue healing, mobility, and strength milestones.
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Strength & Conditioning (S&C) and Sport Science: Designed progressive physical programs based on neuromuscular tests.
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Nutrition and Mental Performance: Supported recovery through diet and psychological resilience.
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Coaching Staff: Integrated on-snow progression once physical benchmarks were met.
3. Objective Monitoring:
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Neuromuscular Testing:
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Force-plate CMJ and SJ asymmetry testing
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80s repeated squat jump test for fatigue-induced asymmetry
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Loaded CMJ for eccentric strength under load
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Isometric strength and Rate of Force Development (RFD) of the leg press, knee extensors, and flexors
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Workload Monitoring:
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Daily tracking of internal load (Session-RPE × session duration) to ensure safe workload progression.
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Milestone Tracking:
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Specific strength, symmetry, and endurance targets set for each phase transition.
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4. Structured Testing and Communication Cadence:
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Every 4-week training block included:
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A 3-day test battery (medical evaluation, neuromuscular testing, fitness testing)
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IPT team debrief to adjust training
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Athlete-coach-team feedback meetings
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Targeted training block implementation
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Scheduled recovery microcycles to manage fatigue.
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What They Found
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Persistent Neuromuscular Deficits:
Despite passing initial RTS criteria (<10% limb asymmetry) at 7 months, detailed testing showed continued deficits in jump asymmetries, RFD, and mechanical muscle function up to 18 months post-surgery. -
Non-Surgical Limb Weakness:
Strength in the “healthy” limb deteriorated over time, demonstrating the need to train and monitor both legs during rehabilitation. -
Fatigue-Induced Symmetry Changes:
Fatigue testing (80s squat jump) revealed that the non-injured limb fatigued faster post-injury, highlighting the need to assess readiness under fatigue conditions. -
Value of the Interdisciplinary Model:
Effective management of uncertainty, athlete buy-in, and better communication across disciplines helped support the physical and mental components of RTS. -
Realistic Timelines:
Even though the athlete resumed snow training at 7 months, true physical restoration (return to pre-injury strength and asymmetry benchmarks) was still incomplete at 18 months.
Competitive Performance Post-Return
While the study provides extensive insight into the athlete’s physical recovery and neuromuscular function post-injury, it does not report on her actual ski racing performance following her return to sport. No race results, rankings, or competition outcomes were documented. As such, it remains unclear how the physical deficits identified—particularly the persistent strength and asymmetry issues—impacted her competitive success. This is an important limitation, as physical recovery does not always equate to performance recovery, particularly in high-risk, high-skill sports like alpine skiing.
Practical Takeaways
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Use Milestones, Not Timelines:
Athletes should progress based on meeting specific physical benchmarks, not just by waiting 6, 9, or 12 months. -
Test Beyond Single Metrics:
Standard hop tests or passing a “90% symmetry rule” may mask persistent deficits; layered, phase-specific testing is critical. -
Prepare for Fatigue:
Include fatigue testing in the RTS process. Athletes may compensate differently when tired, and hidden deficits may emerge. -
Monitor Both Limbs:
Rehab plans must include the “uninjured” limb—strength loss happens symmetrically over time if ignored. -
Pre-Injury Baselines are Gold:
Pre-injury neuromuscular testing provides a far better reference for rehab progression than normative data or uninjured limb comparisons. -
IPT Collaboration is Key:
A team-based, expertise-driven model improves decision-making and athlete support during the complicated, uncertain RTS transition.
Study Source:
Jordan, M. J., Morris, N., Lane, M., Barnert, J., MacGregor, K., Heard, M., Robinson, S., & Herzog, W. (2020).
Monitoring the return to sport transition after ACL injury: An alpine ski racing case study. Frontiers in Sports and Active Living, 2, 12. https://doi.org/10.3389/fspor.2020.00012