50.2 The Main Goal
The main goal is to allow a safe transition between the rehabilitation process and the training process required to accumulate load in order to provide adequate return to play and performance.
From a strictly medical point of view, we subdivide the sports rehabilitation period after injury into four stages (1, initial stage; 2, intermediate stage; 3, advanced stage; 4, return to play) that represent a progressive continuum of therapeutic management, according to the four typical questions the football player asks after injury: “When will I be able: (1) to walk normally? (2) to run normally? (3) to start training on the field? (4) to go back to competitions?” This strategy underlines one of the main themes of sports rehabilitation that objective criteria rather than specific timetables should guide clinical decision-making.
Late rehabilitation or rehabilitation on field corresponds to the third and fourth phase of the global process of sports rehabilitation.
Late rehabilitation program should be performed with on-field training, progressively exposing the player to the football-specific demands.
The phases of rehabilitation are closely related to the stages of healing:
The management of injuries during the stages of healing has been established [4]; however, according to “The clinician who waits for tissue healing before clearing the athlete to return to play will probably find a short-lived career with a sporting team. So, why is there a paradox between the evidence and clinical practice regarding when the athlete should return to play? Return-to-play criteria must depend on the type of injury, demands of sports and the affected body region. Ideally, a battery of accepted clinical criteria are used to guide safe return-to-play decisions. But these are physical assessments based on clinical dogma, with little empirical evidence to support their use, and little consensus regarding what the best criteria are. This highlights the need for evidence to address this knowledge gap—ideally rigorous studies—but a good first step is to have consensus.”
Dynamic loading in the form of exercise rehabilitation can be started as soon as the repair phase has begun [6].
Exercise rehabilitation for an injury is classically described to have three phases (cognitive, associative, and autonomous) [5]. For the football player, an additional phase relevant to return to play is added. The aims of the four phases are presented in Fig. 50.1.
Fig. 50.1
The phases of exercise rehabilitation of the injured player
From the theoretical point of view, the autonomous phase (phase 3) and return to play (phase 4) form the rehabilitation on-field concept.
For the rehabilitation process to be successful, communication between the medical team, player, trainer, and coach is critical.
50.3 When to Start?
The criteria for starting On-Field-Rehabilitation (OFR) are a good joint stability in clinical tests, no giving-way episodes during the preceding phases, minimal or no pain (visual analogue scale [VAS] less than 3/10), minimal effusion, complete range of motion (ROM), and maximal peak torque difference less than 20% between limbs in isokinetic tests. The football player must also be able to run on the treadmill at 8 km/h for more than 10 min [7].
An extremely important criterion to reach the late stage of rehabilitation, the football player must have gained adequate strength and stability in two “key muscles”: (1) dynamic stabilizers of the hip and (2) core stability. These two muscle groups are fundamental for a good rehabilitation and for the football player performance.
50.3.1 Dynamic Stabilizers of the Hip
The six short hip external rotators (superior and inferior gemellus, obturator internus and externus, quadratus femoris, and piriformis) have the capacity to provide hip joint compression and hence dynamic stability during most weight-bearing and non-weight-bearing activities.
The gluteus medius is the dominant hip abductor and is the primary lateral stabilizer of the hip during one-leg stance activities.
The gluteus maximus plays an important role in generating extension and external rotation torque and has the potential to provide hip stabilization by resisting anterior hip force. The gluteal muscles contribute at least 50% to isometric hip extension. If gluteal strength is inadequate, the hamstring muscle can be overloaded and susceptible to injury. This is especially true during sprinting activities. The gluteus maximus acts during running to control trunk flexion of the stance leg, decelerate the swing leg, and extend the hip. Any alteration in the gluteus maximus activation, strength, or endurance places greater demand on the hamstring. Overall the gluteus maximus provides powerful hip extension when sprinting, and the hamstrings help to transfer the power between the hip and the knee joints. Unlike the hamstring and quadriceps, the gluteus maximus usually is neglected in a rehabilitation program of a footballer. Definitely, the gluteus maximus is a “key muscle” for a footballer.
50.3.2 Core Stability
The musculoskeletal core of the body includes the spine, hips and pelvis, proximal lower limb, and abdominal structures. Dynamic stabilization refers to the ability to utilize strength and endurance and motor control in a functional manner through all planes of motion and action despite changes in the center of gravity.
Core exercises train the muscles in your pelvis, lower back, hips, and abdomen to work in harmony. This leads to better balance and stability on the playing field.
Strong core muscles make it easier to do everything from running technique to having a good kicking technique. The stability of the lumbopelvic region is crucial, to provide a foundation for limb movement, to support loads, and to protect the spine. Weak core muscles leave you susceptible to poor posture, lower back pain, and muscle injuries.
Each OFR session takes place outdoors on a grass or synthetic field and is integrated by gym sessions with specific strengthening, flexibility, and neuromuscular exercises. During OFR, the progression of each type of exercise is football specific and follows the principles of strength training and of increasing functional demand performed on progressively broader spaces with respect to the musculoskeletal and neuromechanical components involved in the recovery process.
50.4 Methods of Training and Rehab Interaction
The mechanistic view of human organisms inspired in analytic reductionism and classical cybernetics has deeply influenced sport theory, sport practice, and sport research in the last few decades [4].
“Any living system, including the human body is more than the addition of its parts.” Aristotle
During the last decades, influenced by the general systems theory proposed by Ludwig von Bertalanffy and the models derived from the chaos theory, a new understanding of living beings and their complexity, organization, and relationship with environment as well as their development has been stablished. From this new perspective, human beings in motion are understood as a complex and indivisible entity [5]. Football is not an exception. According to Seirul.lo [6], a new paradigm has been proposed, where the footballer is considered a hypercomplex structure configured by interactions and structures (Fig. 50.2).
Fig. 50.2
Structures configuring the hypercomplex athlete/footballer according to Seirul.lo [6]. Each structure must be considered a manifest of underlying processes. In other words, processes, a network of dynamic relationships between systems, manifest through what we call structures. What we classically call “capacities” are nothing but a sectorial evaluation of the processes occurring in a giving system which configure a given structure
According to Seirul.lo [6], these structures interact with each other and with the environment so the entire network self-structures, acquiring a different structure for each player at any given time, every time, hence the nonlinearity proposed.
This holistic paradigm shift seems ideal for team sports where continuous interaction between teammates, opponents, and objects requires a high level of self-structuring. Therefore, training becomes a unique event, where the footballer “trains and learns.” Exercises should be constructed to provide this dynamic activity, i.e., practices should emphasize high variability and global approach, far from the classical analytical, repetitive, and “closed” tasks. Within that network of structures (Fig. 50.2), none of them is more important than the other; everything is alike. In each workout will be a distinct priority tailored to the needs of the athlete, but in the pre-match, a synthesis of all structures occurs again. In the case of injured players, once the player is ready to train on the field, as proposed by Pol [5], training should not be focused exclusively on the individual but also the collective entity (team).
“Every engine scheme will be strengthened through the variability of practice.”Related posts:
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