Endurance training in soccer: traditional approach

Endurance training in soccer: traditional approach

For a long time, endurance training in soccer was based on improving physiological parameters. This methodology comes from athletics and only aims to improve the cardiorespiratory system, differentiating physical and technical-tactical training. However, soccer has evolved toward a holistic training methodology considers together the physical and technical-tactical aspects in task design. In this regard, it is of great importance that S&C coaches know how to organize the physical load within the coaches’ tactical objectives. Such Seirul.lo established: the aim is not to enhance a specific physical parameter; players must be able to withstand the physical demands required by the game system itself and that of the opponent.  

Therefore, soccer endurance should not be exclusively considered for improving physiological parameters. Although it is not our premise, it is essential to have knowledge of physiological values such as heart rate (HR) or VO2max of our players. These parameters are referred to the intensity of the exercise. The following is a brief summary of the traditional methodology of endurance training using tables.

Pallarés & Morán-Navarro (2012) established training zones based on the improvement of cardiorespiratory capacity:

Endurance training zones in soccer (Pallarés & Morán-Navarro, 2012, modified by Guerrero-Calderon)

Pallarés & Morán-Navarro (2012) also established endurance training methods for these zones:

Endurance training methods in soccer (Pallarés & Morán-Navarro, 2012, modified by Guerrero-Calderon)


Although I have written about the traditional approach of endurance training in this post and it is essential to know how soccer affects the players’ cardiorespiratory system, it is a decontextualized training method and, therefore, inadequate, as it does not represent the real demands of soccer. The current endurance training methodology should consider the following items:

  • Specificity
  • Technical skills 
  • Playing style
  • Opponents
  • Decision taking

If you want me to talk about training methodology from an integrated approach in future posts, leave a comment or share on social networks.


Guerrero-Calderón, B., Klemp, M., Morcillo, J. A., & Memmert, D. (2021). How does the workload applied during the training week and the contextual factors affect the physical responses of professional soccer players in the match? International Journal of Sports Science & Coaching16(4), 994–1003. https://doi.org/10.1177/1747954121995610

Pallarés, J., & Morán-Navarro, R. (2012). Methodological Approach To the Cardiorespiratory Endurance Training. Journal of Sport and Health Research4(2), 119–136.

Slettaløkken, G., & Rønnestad, B. R. (2014). High-Intensity Interval Training Every Second Week Maintains VO2max in Soccer Players During Off-Season. Journal of Strength and Conditioning Research28(7), 1946–1951. 

Solé, J. (2002). Entrenamiento de la Resistencia en los Deportes de Equipo. In Apuntes Master Alto Rendimiento Deportes de Equipo. Byomedic System.

Dr. Berni Guerrero-Calderon

S&C Coach | Rehab Therapist | Performance Analyst

Patellar tendinopathy in sport: epidemiology and treatment

Patellar tendinopathy in sport: epidemiology and treatment

Patellar tendinopathy is a very common injury in sports such as cycling, football or basket, although it can also affect sedentary people whose activity requires active participation of the knee joint. The function of patellar tendon serves as a link between the patella and tibia and is key for the knee extension, as well as other activities such as jumping, bending, going up and down stairs.

This injury does not usually develop inflammation as it is degenerative. The injured tendon shows hypercellularity with an atypical proliferation of fibroblast and endothelial cells among the vascularization. There is a lack of longitudinal collagen fibers, with gaps between their fibers, a rupture of collagen fibers. Assessing the tendon irritability is critical in patellar tendinopathy to determine the severity of symptoms after energy storage and release activities (e.g., sprints, jumps, changes of direction).


Patellar tendinopathy injury is characterized by a stabbing pain under the patella, deep to the tendon. The pain is more pronounced on the knee flexion or when performing any action that requires knee strength. Depending on the severity of the injury, pain may be a limiting factor and prevent full flexion of the knee or the practice of any sporting activity. Early intervention and an adequate rehabilitation program are paramount to avoid aggravation of the injury and chronicity, when the recovery process will be longer and more difficult.

Patellar tendinopathy usually begins with a ‘mild discomfort’ during activity, which ceases immediately after exertion. It is very common ‘not to give it importance’, but if an appropriate rehabilitation program is not performed and the injury becomes symptomatic, the recovery is more difficult since there will be a progressive degeneration of the tendon and the pain will increase, even breaking the tendon. 

Common causes of patellar tendinopathy

  • Stiffness of leg muscles, with shorter ranges of motions.
  • Repetitive stress caused by microtrauma, such as continuous landings and jumps (e.g., volleyball) or constant pedalling. 
  • Inadequate load adaptations or progressions. 
  • Deficient body posture or poor technique. 

In conclusion, all situations involving excessive stress on the tendon that may lead to inflammation or microtears.

Schwartz et al. (2015) establishes the following risk factors:

  • Increased weight. 
  • Wrist-hip ratio.
  • Asymmetry in leg length. 
  • Height of foot arc.
  • Strength and flexibility of quadriceps. 
  • Flexibility of hamstrings.
  • Sports involving continuous jumping and landing.

Treatment of patellar tendinopathy 

The treatment of patellar tendinopathy must be individualized due to the affectation, aggravation, causes and specific requirement of each person can be very different. Consequently, recovery time can vary significatively. If the injury is not advanced and timing of intervention is adequate, recovery does not have to be a long process and even the treatment can be combined simultaneously with the specific practice by reducing the volume of load. There are studies showing that one third of athletes with patellar tendinopathy return to play after 6 months (Malliaras et al., 2015). However, if the treatment is not appropriate or the injury becomes chronic, the recovery process is very tedious and lengthen up to 12-18 months. Finally, the literature shows that 53% of athletes retire after this injury.

The recovery process of patellar tendinopathy may be slightly painful for the athlete as the intensity or load of the exercises will be regulated according to his subjective perception of pain. In this sense, pain rating with the visual analogue scale (VAS) is a good method to evaluate the workload. 

I usually work with an athlete’s pain perception of 3-5 on the VAS (Malliaras et al., 2015), especially early in the recovery process. Nonetheless, this can vary depending on the athlete, severity of the injury, competition demands and the risk you are willing to take. Anyways, I do not consider appropriate to exceed 6 on the VAS. 

Appropriate guidelines in the treatment of this injury:

  • Reduce the load volume. 
  • Isometric contractions at 30-60º (especially early in the recovery process).
  • Slow contractions with high resistance.
  • Eccentric contractions of quadriceps.
  • Eccentric squat on declined surface of 20-25º, eliminating the concentric phase of movement. 
  • Strength exercises with closed kinetic chain.
  • Strengthening and stretching of the musculature implicated in the flexion-extension of the knee (quadriceps and hamstrings) to complete the full range of motion.
  • Progression from bilateral to unilateral exercises.
  • Progression by increasing the speed of execution and towards SSC exercises.
  • Assess unilateral strength with declined 90º-squat test using the VAS immediately- and 24 hours after the exercise. 
  • Application of ice to the affected area. 
  • Combine training and physiotherapy. 

Below, I propose a generic exercise program for the rehabilitation of patellar tendinopathy for the initial stages of the process. It is recommended to perform this program 3 times per week and progress gradually increasing the load and speed of execution, and towards from bilateral to unilateral movements. The principles of individualization and progression of the load must be considered for an optimal rehabilitation process. In addition, as previously mentioned, reducing the volume of activity is key in the recovery of this injury.

Ankle dorsal flexion3x15reps each leg
Seated straight Leg Raise (overloaded)6×20” each leg
Isometric bilateral squat (overloaded)4×45” / 60” Recovery
Eccentric bilateral squat on declined surface (20-25º)4x10reps / 45-60” Rec
Eccentric unilateral squat on declined surface3×6-8reps / 45-60” Rec
One-leg stability on bosu4×25” each leg / 20” Rec
Alternating front lunges4x16reps / 30” Rec


  • Clifford, C., Challoumas, D., Paul, L., Syme, G., & Millar, N. L. (2020). Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ Open Sport & Exercise Medicine, 6(1), e000760. 
  • Lim, H. Y., & Wong, S. H. (2018). Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiotherapy Research International23(4), 1–15.
  • Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar tendinopathy: Clinical diagnosis, load management, and advice for challenging case presentations. Journal of Orthopaedic and Sports Physical Therapy45(11), 887–898. 
  • Muaidi, Q. I. (2020). Rehabilitation of patellar tendinopathy. Journal of Musculoskeletal Neuronal Interactions, 20(4), 535–540.
  • Murtaugh, B., & M. Ihm, J. (2013). Eccentric Training for the Treatment of Tendinopathies. Current Sports Medicine Reports, 12(3), 175–182. 
  • Schwartz, A., Watson, J. N., & Hutchinson, M. R. (2015). Patellar Tendinopathy. Sports Health7(5), 415–420. 
  • Van Ark, M., Van den Akker-Scheek, I., Meijer, L. T. B., & Zwerver, J. (2013). An exercise-based physical therapy program for patients with patellar tendinopathy after platelet-rich plasma injection. Physical Therapy in Sport14(2), 124–130. 

Dr. Berni Guerrero-Calderón

S&C Coach | Rehab Therapist |Sport Scientist

If you have any doubt, do not hesitate to leave your comment. If you liked the post, share it on social media!

This article has been made based on the references showed, other studies reviewed but not showed and according to the experience and knowledge of the author. In this way, it may include subjective ideas and opinions not contrasted in the research.

The Anterior Cruciate Ligament knee injury in sport: keys for an optimal rehabilitation process

The Anterior Cruciate Ligament knee injury in sport: keys for an optimal rehabilitation process


The Anterior Cruciate Ligament (ACL) knee tear is very common in contact and pivoting sports such as soccer, basket, handball or ski. It is considered one of the most severe injuries in sport as it usually requires surgery and a long recovery process. 

There is a high percentage of athletes who are not able to return to their pre-injury level or even finish their sport careers after suffering this injury. It is therefore paramount to develop an adequate rehabilitation program. 


The ACL is a broad ligament that originates from the posterolateral aspect of the intercondylar notch and inserts into the anterior tibial plateau, just lateral to the tibial spine. It is composed of 2 primary functional bundles: 

  • The anteromedial (AM) bundle: It is the primary restraint to anterior tibial translation in the flexed knee. It is generally composed of isometric fibers with increased tightens in flexion. The AM-bundle tightens is reduced from 0 to 30º, and increase from 30 to 130º.
  • The posterolateral (PL) bundle: provides additional rotational stability to the knee. It is generally composed of anisometric fibers that wrap the AM-bundle during knee flexion forming an arch. The PL-bundle tightens in extension: it gradually decreases from 0 to 90º of flexion and increase from 90º onwards.

Figure 1. Role of AM and PL bundles during knee flexion (retrieved from Sonnery-Connet & Colombet, 2016).

Function of ACL

The ACL is the major stabilizing structure of the knee-joint:

  • Avoid anterior tibial translation over the femur (main function).
  • Restrain internal rotation of the tibia.
  • Resist varus and valgus forces at the knee.

Main injury mechanisms

Figure 2. Distinctive body position in ACL injury (retrieved from LaBella, Hennrikus & Hewett, 2014)

The ACL is commonly injured via a non-contact mechanism during sports participation (70%), particularly in sports involving jumping, pivoting and cutting maneuvers. There is a distinctive body position that is related to non-contact ACL-injury (1) (Figure 2):

  • Internal rotation of the hip.
  • Semi-flexion of the knee, close to full extension.
  • Foot planted into the ground.
  • The body is decelerating, resulting in a dynamic knee valgus.

In the systematic review and meta-analysis of Pappas et al. (2), 4 theories are proposed as to the causes that significantly increase the risk of ACL injury in athletes:

  1. Ligament dominance theory: athletes at high ACL injury risk perform landing and cutting maneuvers with excessive dynamic knee valgus, hip adduction and hip internal rotation. 
  2. Trunk dominance theory: deficits in trunk control lead to increased risk for ACL injury. 
  3. Quadriceps dominance theory: excessive quadriceps forces relative to posterior chain recruitment place the ACL at high risk for injury.
  4. Leg dominance theory: large leg-to-leg asymmetries.

In soccer, this injury is usually occurred in the following situations:

  • Internal turns with the knee semi-flexed and the foot planted on the ground. 
  • On jumps when the athlete lands with the knee extended. 
  • Aggressive actions that cause a dynamic knee valgus (e.g., after an opponent’s thrust).

Injury incidence

Relevant data regarding the injury incidence for the management of ACL tear are shown below (3–5):

  • RTP rate: 82%
  • Rate of preinjury level: 63%
  • 35-45% of athletes do not return to competitive sport (RTS). 
  • Even at elite-level, 20-25% of athletes are incapable to RTS.
  • In professional soccer, RTS is very high (>90%) one year after injury. However, only 65% of players are still competing at the top level 3 years after ACL reconstruction (ACLR).
  • Risk of ACL reinjury in the following two years: 15% (all ages). 
    • Young athletes (<25 years): 30% in the following two years.
  • The risk of reinjury is x30-40 higher in matches than in training.
  • The risk of ACL tear is higher in women than in men.

In addition, athletes with a follow-up ≥ 24 months reported a much higher rate of RTS than those with a follow-up < 24 months (65% and 38%, respectively) (3). However, these values may vary according to the type of sport analysed.

Partial-tear vs total-tear of ACL

Among ACL injuries in sports, total ligament tear is the most common. Partial tears accounts for only 10-28% of all ACL tears, being more prevalent in men and young athletes (6). The injury incidence is higher in the PL-bundle as it receives greater stress. Also, partial tears progress to total tears in 50% of cases (7).

On the other hand, when an athlete is injured with an ACL-tear, it is very common that other structures of the knee, such as meniscus, are also affected (8). These authors found in their review that approximately 50% of acute ACL injuries also involved meniscal tears. In addition, the risk of osteoarthritis is higher in patients who have had a concomitant meniscal injury compared to an isolated ACL injury (48% vs 13%, respectively). The risk of concomitant meniscal injury is lower with partial tears (24%) than total tears (42%) of ACL. Accordingly, ACLR is warranted in those patients to reduce the risk of future osteoarthritis. 

The recovery period for partial tears is 5 to 7 months, while for total tears is 9 to 12 months.

Clinical evaluation and tests

Manual tests to evaluate and diagnose an ACL tear: 

  • Lachman test (for anterior knee instability)
  • Anterior drawer test (for anterior knee instability)
  • Pivot-shift test (rotatory knee instability)

Test to assess the damage on Associated structures:

  • Valgus/varus stress test (for collateral ligaments)
  • McMurray’s test (for menisci)
  • Posterior drawer test (for PCL
  • Reverse pivot shift test (for posterolateral complex)

*Either way, magnetic resonance imaging (MRI) is the gold standard test to confirm an ACL tear.

ACLR vs conservative treatment

ACL reconstruction is the most common surgical procedure after an ACL tear, and is especially recommended for young athletes. However, some authors have argued that conservative treatment for ACL tears may provide sufficient knee stability for patients who do not have the desire to engage in ‘high-risk’ activities, such as the practice of sports like soccer, basket or ski. It should be noted also that the risk of reinjury with conservative treatment is 50% (7).

For developing the conservative treatment, it is very important that the athlete must be a coper. According to the revision of Secrist et al. (8), non-copers show several properties different from copers, such as worse balance and gait patterns that cause excessive internal rotation of the tibia, among others. Some characteristics that potential copers must have in order to perform conservative treatment are: 

  • No concomitant injuries
  • LSI ≥ 80% (for all hop tests)
  • > 80% KOS-ADLS
  • > 60% IKDC 1000 (self-report of knee function)
  • ≤ 1% subjective report of knee giving way

In patients with isolated ACL-tears, there is also the option of delaying ACLR for up to 6 months and performing perturbation exercises during this period to develop dynamic mechanisms while the final decision of surgery is determined. Either way, ACLR must be addressed when there is concomitant meniscal injury or symptomatic instability in order to reduce the risk of additional knee injuries. According to the current literature, all ACL tears in sport should be treated with ACLRs as soon as possible. 

Rehabilitation program after ACLR

In high-level sport, the period of time between the athlete performing ACLR and RTS is usually between 6 and 9 months. However, most authors consider a short period of time to adequately recover this injury (3,5,7,9–11). Van Melick et al. (11) recommend a minimum recovery of 12 months after an ACLR in soccer to return to competition with lower risks. Nonetheless, several authors have found no differences between an accelerated rehabilitation program (≤ 6 months) compared to a ‘common’ program (12). In this sense, the rehabilitation program is highly affected by the individual characteristics of the athlete, such as the injury history, age or gender, among others.

Before-surgery phase

Several authors recommend starting the rehabilitation program before ACLR for the following reasons (11):

  • Full knee extension deficit before surgery is the main risk factor for extension deficit after ACLR. 
  • Quadriceps strength deficit > 20% prior to surgery may negatively affect the athlete during the two years after ACLR.
  • Starting rehabilitation properly before ACLR ensures better knee function for two years after ACLR.  

Early phase (4-6 weeks post-surgery)

  • The rehabilitation process should begin 24 hours after the ACLR with assisted mobility exercises.
  • Controlling pain and swelling is one of the most important goals in the early postoperative rehabilitation stage.
  • Light-WB immediately after surgery does not affect knee laxity and reduces anterior knee pain. However, it should only be performed if the movement pattern is adequate and there is no pain (11).
  • Cryotherapy is recommended to reduce swelling.
  • Neuromuscular electrical stimulation (NMES) can be useful to improve the quadriceps strength during this phase when movement is limited, in addition to promote the activation and re-education of voluntary contraction.

Goals (13,14):

  • Minimize pain and swelling.
  • Protect the healing graft.
  • Minimize the effect of immobilization.
  • Establish a normal gait pattern.
  • Eventually discontinue crutch use.
  • Achieve 90-120º of flexion and full extension.
  • Promote quadriceps function and good quadriceps control (neuromuscular control).
  • Restore the ability to perform a straight-leg raise (SLR) without a quadriceps lag.
  • Progression to full weight bearing (WB).

Criteria for progressing to the next phase:

  • Walk normally without crutches or gait deviation
  • Full passive knee extension symmetric to the non-involved knee.
  • 100-120º of knee flexion.
  • No evidence of an extensor lag.
  • Minimal effusion or other signs of active inflammation.

Strengthening phase (4-6 weeks to 6 months post-surgery)

  • Progression of WB in closed kinetic chain (CKC) and non-WB in open kinetic chain (OKC).
  • First 3 months after surgery:
    • Limited ROM between 90-60º (for non-WB knee extensions).
    • ROM 0-60º for WB exercises.
  • >3-4 months: 
    • OKC knee-extensions through full arc of motion. 
    • Initiating OCK knee-flexions to increase the strength of hamstrings (> 6 weeks).
    • CKC progression of ROM 75-90º (WB exercises). 


  • Proper technique.
  • Avoiding compensatory mechanisms.
  • Continuing progression of strengthening.
  • Neuromuscular control. 
  • Train the balance and proprioception.
  • Core stability training.
  • Jogging. 
  • Preparation for the return to activity and sports stage.

Criteria for progressing to RTP phase

  • Appropriate strength: Limb Symmetry Index (LSI) (3,4,9,11,15): 
    • LSI≥90% 
    • Specific for pivoting sports: LSI ≥100%
  • Achieve good balance.
  • No pain or gait difficulties.
  • *Gathering the criteria for progressing to RTP phase before starting reduce the risk of reinjury by 75-84% (4).

Return to play (RTP)

In the RTP phase the athlete should be progressively incorporated into the team’s training while continuing his specific rehabilitation program.


  • Complete the entire functional rehabilitation spectrum.
  • Full return to the patient’s previous level of daily, occupational, and athletic activity, and sports participation.
  • Gradual increase in specific function.
  • Strengthening exercises through the full ROM and 
  • Enhance NM control.
  • Progression to full-effort sprinting, cutting and plyometric activities.
  • Quadriceps index ≥85%, appropriate ROM, strength, proprioception and cardiovascular capacity.
  • Progressive incorporation to team training until completing the full session normally. 

Criteria to return to competition (RTS):

  • LSI strength index of the Knee flexors and extensors:
    • Pivoting sports: LSI = 100%
    • Other sports: LSI ≥ 90%
  • LSI-index hop tests: LSI > 90% (all sports)
  • Subjective perception of having an appropriate level readiness for competition (ACL-RSI scale): no fear, good sensations.
  • Adequate subjective self-perception of function and symptoms (IKDC 1000 or IKDC 2000).
  • Risk factors for ACL reinjury: increased valgus, low hip internal rotation with asymmetry in knee extension at initial contact during a vertical jump at landing, and postural stability deficits during single leg stance.
  • Athletes with ACLR show impaired hip-ankle coordination in dynamic 1-leg activities.

At high-level sport, the RTS is usually after 6 months of ACLR. However, there is a high risk reinjury from 6 to 12 months. Accordingly, biological and functional deficits last up to 2 years after ACLR (5). Most authors recommend a recovery process of 12 months before returning to competition. In addition, environments should be as realistic and context-specific as possible when evaluating the ability to RTS: under fatigue and reactive situations. Finally, it is paramount to take into account the athlete’s self-perceived symptoms/function and psychological readiness for RTS due to the increased percentage of athletes with a fear of reinjury after an ACL tear.


  • The implementation of specific prevention programs will reduce the risk of ACL injury in sport. These programs must emphasize correction of biomechanical technics individually in order to improve neuromuscular control. 
  • The specific exercises’ program and follow-up of the rehabilitation process after ACLR should be at least 24 months, despite starting to compete 9-12 months after surgery.
  • Currently an elevated number of tests and clinical evaluations are performed for RTS in sport. However, the literature shows adverse results in the recovery of this injury in sport. Webster & Feller (16) consider that more focus should be placed on identifying a smaller number of tests that are more predictive.
  • The hop performance tests are the most consistent predictors of a subsequent RTS.
  • It is paramount to take into account self-perceived symptoms/function and psychological readiness of the athletes in the decision of RTS.  
  • The risk of ACL tears and reinjury is greater in young athletes < 25 years.
  • The RTS should be 9 to 12 months after ACLR.
  • ACLR is recommended after ACL tear among athletes, especially in contact and pivoting sports.
  • The conservative treatment, if applied, may only be performed by copers.
  • If applied, only copers may perform conservative treatment. 
  • Although is essential in the rehabilitation programs after ACLR to optimize and attain proper gait and quality patterns, it should be noted that ACL injuries in sport do not usually occur under pre-planned movements. Therefore, athletes should simulate competitive conditions in training prior to RTS: under fatigue and reactive situations.
  • It is essential to have load management strategies during the RTP-phase to ensure optimal recovery and adaptation.

If you liked this post and you would like me to publish a practical and phase-detailed guidance of rehabilitation program after an ACL tear in sport, follow me on social media and share this publication by mentioning me!


  1. LaBella CR, Hennrikus W, Hewett TE. Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention. Pediatrics. 2014; 133(5): e1437–50.
  2. Pappas E, Nightingale EJ, Simic M, Ford KR, Hewett TE, Myer GD. Do exercises used in injury prevention programmes modify cutting task biomechanics? A systematic review with meta-analysis. Br J Sports Med. 2015; 49(10): 673–80.
  3. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and meta-analysis of the state of play. Br J Sports Med. 2011; 45(7): 596–606.
  4. Buckthorpe M. Optimising the Late-Stage Rehabilitation and Return-to-Sport Training and Testing Process After ACL Reconstruction. Sport Med. 2019; 49(7): 1043–58.
  5. Dingenen B, Gokeler A. Optimization of the Return-to-Sport Paradigm After Anterior Cruciate Ligament Reconstruction: A Critical Step Back to Move Forward. Sport Med. 2017.
  6. Sonnery-Cottet B, Colombet P. Partial tears of the anterior cruciate ligament. Orthop Traumatol Surg Res. 2016; 102(1): S59–67.
  7. Yadav S, Singh S. Analysis of partial bundle anterior cruciate ligament tears- diagnosis and management with ACL augmentation. J Clin Orthop Trauma. 2020; 11: S337–41.
  8. Secrist ES, Frederick RW, Tjoumakaris FP, Stache SA, Hammoud S, Freedman KB. A Comparison of Operative and Nonoperative Treatment of Anterior Cruciate Ligament Injuries. JBJS Rev. 2016; 4(11): 1.
  9. Czuppon S, Racette BA, Klein SE, Harris-Hayes M. Variables associated with return to sport following anterior cruciate ligament reconstruction: A systematic review. Br J Sports Med. 2014; 48(5): 356–64. 
  10. Fallaha M, Belzile S, Martel-pelletier J, Pelletier P, Feldman D, Sylvestre M. Clinical diagnosis of partial or complete anterior cruciate ligament tears using patients ’ history elements and physical examination tests. PLoS One. 2018; 13(6): 1–15. 
  11. van Melick N, van Cingel REH, Brooijmans F, Neeter C, van Tienen T, Hullegie W, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus. Br J Sports Med . 2016; 50(24): 1506–15.
  12. van Grinsven S, van Cingel REH, Holla CJM, van Loon CJM. Evidence-based rehabilitation following anterior cruciate ligament reconstruction. Knee Surgery, Sport Traumatol Arthrosc. 2010; 18(8): 1128–44.
  13. Yabroudi MA, Irrgang JJ. Rehabilitation and Return to Play After Anatomic Anterior Cruciate Ligament Reconstruction. Clin Sports Med [Internet]. 2013; 32(1): 165–75.
  14. Malempati C, Jurjans J, Noehren B, Ireland ML, Johnson DL. Current Rehabilitation Concepts for Anterior Cruciate Ligament Surgery in Athletes. Johnson DL, editor. Orthopedics. 2015; 38(11): 689–96.
  15. Micheo W, Hernández L, Seda C. Evaluation, management, rehabilitation, and prevention of anterior cruciate ligament injury: current concepts. PM R. 2010; 2(10): 935–44.
  16. Webster KE, Feller JA. Who Passes Return-to-Sport Tests, and Which Tests Are Most Strongly Associated With Return to Play After Anterior Cruciate Ligament Reconstruction? Orthop J Sport Med. 2020; 8(12): 1–8. 

Dr. Berni Guerrero-Calderón

S&C Coach | Rehab Therapist |Sport Scientist

If you have any doubt, do not hesitate to leave your comment. If you liked the post, share it on social media!

This article has been made based on the references showed, other studies reviewed but not showed and according to the experience and knowledge of the author. In this way, it may include subjective ideas and opinions not contrasted in the research.

Rehabilitation and RTP process after meniscal repair in sports

Rehabilitation and RTP process after meniscal repair in sports


A meniscus is a fibrocartilaginous anatomical structure divided in two parts and placed in the knee-joint cavity between the femur and the tibia. Its main functions are the knee-joint stabilization and reduce the stress by increasing the contact areas between the femur and the tibia. 

The meniscus injury incidence is high in contact and pivoting sports such as soccer, basket or handball. The loss of meniscal tissue increases the direct contact between the femur and the tibia, which results on premature arthrosis and long-term functional decline. Preservation of meniscal function is among the most important goals for athletes. Therefore, the meniscal repair is an important procedure that aims to preserve tissue and prevent future arthrosis.

Meniscal repair rehabilitation

There is a multitude of factors contributing to meniscal healing which affect to the rehabilitation protocols following meniscal repair.

  • Tear location (peripheral vs central) and pattern (longitudinal, radial, complex).
  • Meniscal vascular supply is the most important factor influencing the meniscal healing. The vascular supply is very low, although there are differences according to the meniscal area:
    • Peripheral area (red-red zone); 30% vascular supply. 
    • Inner area (red-white and white-white zone); relatively avascular.
  • Timing and type of meniscal tear may also impact healing:
    • Acute, traumatic tears: higher healing rates than chronic and atraumatic tears.
    • Longitudinal tears: more amenable to repair due to their vertical orientation.
    • Radial tears: extending to the central relatively avascular ‘white-white’ zone. Are more challenging for healing. 
  • Age
  • ROM and weight-bearing capacity before the meniscal repair.
  • Other factors (tear chronicity, concomitant injuries, alignment, tissue quality, surgical technique) may impact physical therapy protocols and clinical outcomes.

Rehabilitation guidelines specific to the tear’s characteristics:

  • Anterior-posterior longitudinal tears <3 cm; weight-bearing as tolerated without a brace. ROM progressed to 125° between 3 and 6 weeks. RTP was allowed after 3 months. 
  • A-P longitudinal Tears >3 cm; weight-bearing was allowed in a locked brace. ROM was limited to 0°–125° until 6 or 8 weeks. RTP: 3 months. 
  • Complex and radial tears; weight-bearing as tolerated with brace ranging from 0° to 125° for 6 to 8 weeks. RTP between 4 and 5 months.

Traditional vs accelerated rehabilitation approaches

The literature shows two approaches of postoperative rehabilitation protocols: protective vs accelerated. The traditional approach is based on the leg immobilization in extension, non-weight-bearing and limiting knee flexion to 90º for the first 4 to 6 weeks. The accelerated approach is based on the athlete progression and consists on earlier weight-bearing and unrestricted ROM, with individualized timing. However, there is controversy regarding to the adequacy of leg immobilization (quadriceps atrophy and fibrovascular scar formation). Besides, authors have not found any differences in failure rates or functional performance on RTP, and athletes return to play 2-fold faster with accelerated rehabilitation compared to traditional approach (10 weeks vs 20 weeks). Therefore, the accelerated process seems more adequate. 

Accelerated approach: phases of rehabilitation after a meniscal repair.

Protective Phase (weeks 0 to aprox 6)

  • It is usually the most time-driven phase of rehabilitation to allow an adequate period of meniscal healing.
  • Early Focus (0-3 weeks): pain/edema control, early patellar mobilization, full ROM (without a brace*), and quadriceps neuromuscular training, Core, aerobic training.
  • The aerobic fitness should never be the limiting factor in the RTP phase of training.
  • Peripheral longitudinal tears may be advanced from toe-touch weight-bearing in extension to full weight-bearing in extension over the first 6 weeks.
    • ROM may progress rapidly from 0-90º by the end of week 1; to 0-135º by week 4. 
  • Complex or radial repairs may be held at partial weight-bearing longer.
    • ROM limiting flexion to 70º up to week 3, 90º at week 4, and 120º at week 5. 
  • Hamstring strengthening should be avoided.
  • Normalized gait pattern free of bracing is the goal at 6 weeks.
  • Criteria for progression (to restorative phase): full passive ROM, no effusion, and neuromuscular control of quadriceps.

*Depends of the tear’s type.

Restorative Phase (weeks 6 to 12)

  • Focus: closed kinetic chain strengthening, squatting >90º flexion, lunges, and step-ups, initiating hamstring strengthening, proprioceptive and single-leg balance training.
  • Criteria for progression: once the patient demonstrates full active ROM and adequate single-leg dynamic knee control.

Return to Activity (weeks 12 to 16)

  • Early focus: increasing neuromuscular control and building strength, isokinetic exercises, jumping and landing maneuvers; progress to plyometry, changes of directions (CODs). 
  • Late focus: sport-specific high-load and high-speed maneuvers that simulate the on-field requirements of competition in a controlled environment (specifically by athlete and positional demands).
  • Dynamic maneuvers challenge the athlete both eccentrically and concentrically in a way that continues to recreate the unpredictable and varied environment.
  • Particular attention to landing with too little knee flexion or breakdowns in balance.
  • Return to jogging:
    • Peripheral tears: it may be possibly from week 12, when the patient has appropriate strength, good frontal and sagittal plane control, and performs low-level agility exercises without pain.
    • Complex tears: from 16 to 24 weeks.
  • Criteria for progression: absence of effusion, full active ROM, 70% operative leg strength versus contralateral, and Lysholm and SANE subjective scores >75 points.
  • Observation of subtle signs of breakdown in core kinetics such as decreased knee flexion, poor postural control, or “leading” with the opposite leg must be recognized and addressed during this protected period before the athlete is released to return to full competition.


  • Shared decision between the physician, the athlete, and the rehab trainer.
  • A second-look arthroscopy before RTP may be indicated if one is concerned with reinjury or persistent pain, it is not recommended in an asymptomatic athlete because of the potential risks and costs.
  •  Criteria for progression: full, symmetric, pain-free ROM at the knee, no obvious strength discrepancies, ability to perform single leg squat, normal running mechanics and sufficient neuromuscular control when performing dynamic sport-specific activities.
  • Several factors may influence healing and increase the risk of reinjury following meniscal repair: tear type, rim width/zone of tear, medial versus lateral meniscus tear, and the presence of concomitant injuries.
    • Tears having rim widths >3 mm being significantly more likely to fail.
    • no significant difference exists regarding isolated medial vs lateral meniscus repair.
  • Concomitant meniscal injuries in the presence of acute ACL rupture is extremely common: up to 80% ACL ruptures to have associated meniscal tears.
    • The forces about the meniscus to increase up to 200% in the ACL deficient knee, suggesting an increased rate of failure following meniscal repair in an ACL deficient knee.
  • % of RTP rate following meniscal repairs: 80 to 95%. 
  • RTP timing:
    • Isolated meniscal tear: 5.6 months (3-8 months).
    • ACL + meniscal tear: 11.8 months.

Meniscal repair outcomes

Meniscal repair can provide excellent results for RTP. Multiple repair techniques: inside-out (gold standard), all-inside, and open repair. 

Meniscal repair vs Meniscectomy

  • Isolated meniscectomy has been performed in situations whereby there is nonviable meniscal tissue or non-satisfactory healing potential.
  • Isolated partial lateral (LM) vs medial meniscectomy (MM)
    • Athletes return to previous level at an average of 5 to 7 weeks.
    • Faster returning for LM, but may presents adverse events; persistent effusions and lateral joint line pain or required subsequent arthroscopic surgery.
  • Partial meniscectomy can provide an opportunity for more rapid RTP than meniscal repair, but there is significant risk of future cartilage degeneration.
  • Although partial meniscectomy generally produces good to excellent results with low complication rates, several studies have reported persistent knee pain requiring athletes to decrease their activity level.
  • Partial meniscectomy is frequently preferred by patients and surgeons to allow earlier RTP. Furthermore, it presents excellent short-term results, necessary in high-level sport.
  • Meniscal repair records significantly high functional scores at long-term follow-up, but requires a longer rehabilitation period and is a more technically challenging procedure than partial meniscectomy.


  • Barcia AM, Kozlowski EJ, Tokish JM. Return to Sport After Meniscal Repair. Clin Sports Med. 2012; 31(1): 155–66.
  • Wiley TJ, Lemme NJ, Marcaccio S, Bokshan S, Fadale PD, Edgar C, et al. Return to Play Following Meniscal Repair. Clin Sports Med. 2020; 39(1): 185–96. 
  • Spang RC, Nasr MC, Mohamadi A, Deangelis JP, Nazarian A, Ramappa AJ. Rehabilitation following meniscal repair: A systematic review. BMJ Open Sport Exerc Med. 2018; 4(1): 1–12. 
  • Kozlowski EJ, Barcia AM, Tokish JM. Meniscus Repair: the role of accelerated rehabilitation in return to sport. Sports Med Arthrosc. 2012; 20(2): 121–6.

Berni Guerrero-Calderón

S&C Coach | Rehab Therapist | Sport Scientist

If you have any doubt, do not hesitate to leave your comment. If you liked the post, share it on social media!

This article has been made based on the references showed, other studies reviewed but not showed and according to the experience and knowledge of the author. In this way, it may include subjective ideas and opinions not contrasted in the research.

Pin It on Pinterest