The effects of different rehabilitation training modalities on isokinetic muscle function and male athletes’ psychological status after anterior cruciate ligament reconstructions
Authors: Kasmi Sofien , Sariati Dorsaf , Hammami Raouf , Clark Cain C. T. , Chtara Mokhtar , Hammami Amri , Salah Fatma Zohra Ben , Saeidi Ayoub , Ounis Omar Ben , Granacher Urs , Zouhal Hassane 
Published: March 2023

Abstract
Background
Previously, researchers reported performance enhancements following long-term plyometric training in athletes with anterior cruciate ligament reconstruction (LCA). However, the effects of combined eccentric and plyometric training on measures of isokinetic strength and psychological statues in male athletes have not been examined yet. Knowledge on the effects of combined eccentric and plyometric training help to better plan and program rehabilitations sessions and thus return-to-sports.

Objective
This study sought to compare the effects of three different rehabilitation training programs, eccentric training (ECC), plyometric training (PLYO), or combined eccentric and plyometric training (COMB), on psychological measures (kinesiophobia [TSK-CF], functional knee assessment, knee injury and osteoarthritis outcome score [KOOS], international knee documentation committee 2000 questionnaire [IKDC], and knee flexor and extensor isokinetic muscle performance (peak torque [PT], total work, ratio [R-HQ], and ratio of total work [R-TW]) at different angular velocities post ACL surgery in male elite athletes.

Methods
Forty elite male athletes from different sports (e.g., athletics, team sports) with ACL reconstruction participated in this study. The study started after a 14-weeks post-surgery rehabilitation program, which was identical for all subjects. After this initial rehabilitation period, athletes were randomly assigned to three experimental groups, ECC (n = 10), PLYO (n = 10), and COMB (n = 10), and a control group (CON: n = 10). Testing was conducted pre- and post-the 6-weeks intervention period and included the TSK-CF, KOOS, and IKDC. Peak torque of the knee extensors/flexors was tested at 90, 180, 240 °/s, after the 6-weeks training program only.

Results
Participants’ adherence rate was 100% across all groups and none reported any training or test-related injury. No significant between-group baseline differences (pre-6-weeks intervention) were observed for any of the reported psychological and muscle strength parameters. Significant group-by-time interactions were found for TSK-CF (p = 0.001, d = 2.85), KOOS (p = 0.001, d = 1.31), and IKDC (p = 0.001, d = 1.07). The post-hoc analyses indicated that COMB showed larger pre-post improvements for all psychological variables (p < 0.001, d = 2.95 to 13.15), compared with PLYO, ECC, and CON. Contrast analyses demonstrated that COMB yielded significantly greater improvements compared with CON, PLYO, ECC for all isokinetic parameters at all three angular velocities (all p < 0.001, d = 0.99 to 4.61).

Conclusion
The results showed that COMB induced greater gains for measures of psychological status and isokinetic muscle strength compared with single-mode PLYO and ECC in elite male athletes during a post-surgery ACL rehabilitation period. Accordingly, it is recommended to implement COMB as an effective rehabilitation means to improve knee function in male elite athletes.

Trial registration
This study does not report results related to health care interventions using human participants and therefore it was not prospectively registered.