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The right way to return from a soccer injury

This is an excerpt from Complete Conditioning for Soccer by Ryan Alexander.

Return-to-Play Process

To bring this text to completion, we must discuss the often inevitability of injuries. The objective of this section is to provide a guidance or avenue of approach for common injuries suffered in soccer—a template for return to play. Even with the most efficient and robust preparation and monitoring, players will suffer contact or noncontact injuries. In this section, we will address both types of injury as well as the significant difference in consideration for joint versus muscle injuries, and lastly catastrophic versus acute or short-term injuries.

Let us first lay out the entire return-to-play process, and then we will backtrack to discuss each step in detail.

  1. Clinical phase
  2. Functional and conditioning phase
  3. Conditioning
  4. Soccer-specific introduction
  5. Position-specific movement and coordination
  6. Reactive phase
  7. Match simulation (standardized)

Clinical Phase

Any injury—contact or noncontact, muscle or joint, short-term or catastrophic—needs to be evaluated by a qualified sports medicine practitioner. This collaboration is invaluable. The sports medicine practitioner will accurately diagnose and document the athlete's condition, including the severity of the injury. Based on the practitioner's evaluation, they will propose a timeline for return to play, highlighting key assessment benchmarks.

With the help of the sports medicine professional, we want to control the physiological response to the injury, whether by rest, unloading, cold therapy, or alternative treatment, to minimize the severity of the damage. We also want to restore strength and range of motion through and around the injured site and help the athlete understand the return process so the athlete has realistic expectations at each step.

During this stage, the athlete should display proficiency in movement and force production for forward linear movement patterns (i.e., walking, jogging, and running). We don't want to see limping or gait limitations as the athlete progresses to the functional and conditioning portion of the return-to-play process. The physical preparation specialist and sports medicine professionals collaborate to prescribe simple bilateral to unilateral strength progressions. Exercises accomplish these objectives:

  • Strengthen the site of the injury and its surrounding musculature. For example, rehabilitating a right hamstring strain does not mean to focus strengthening exercises on the right hamstring only. Training must limit the development of strength asymmetries or poor movement patterns that might negatively impact the athlete.
  • Positively influence the athlete's postural and activation habits. When an injury occurs, it is common for the athlete to exhibit compensation, depending on the site of the injury. In the early phases of rehabilitation, sports medicine professionals should constantly assess the athlete to identify any compensations and limit their influence.

Functional and Conditioning Phase

This step also takes place in a standardized, closely supervised environment, usually in the gym and training room when those resources are available. At this point, the athlete should be presenting daily without movement limitations when standing, sitting, walking, and performing unilateral movements.

This is the first step in which the athlete produces force in a simplified movement pattern at an increased or elevated intensity. Often this is done first in unweighted or partially weighted conditions such as while using an underwater treadmill or a low-gravity movement apparatus—resources that are scarce in some situations. Those without such equipment could substitute a jog in a pool with a flotation device that keeps the weight off the injured site.

The concentric-eccentric contraction of the lower extremities around the hip and knee joint involve various transmissions of force through numerous neuromuscular junctions. The interruption that occurs as a result of the average hamstring strain can temporarily alter the signaling between these muscle groups. Unweighting the athlete reduces the demand of forces transmitted through the muscle, thereby managing the volume at the injured site. With progressive unweighting, the muscle group of interest can be slowly reintroduced to the full effect of the ground reaction forces that will need to be carried once the athlete achieves higher intensities.

Protocols for consideration can vary depending on the severity of the injury and time out, but consider an incremental progression that correlates with the time out as presented in table 10.1.

During this period, both the athlete and practitioner provide feedback on the player's gait; pay attention to limiting compensations or unnatural movements within the running movement. The player gives subjective feedback on feelings and sensations at and around the site of the injury. The physical preparation coach must be involved in this process as well and communicate with both the athlete and the sports medicine professional so everyone understands when to progress the player to a fully weighted movement. The intensity prescription is given as a reference point.

Table 10.1 Unweighted Running Progression

Once the athlete is proficient in an unweighted environment, consider progressing to a force-assisted environment for one or two sessions to be certain the athlete can maintain an unhindered running gait. Traditionally this is accomplished by using a treadmill. Starting with low speeds, relative to the age and training level of the athlete, a prescription of two or three working sets of four to five minutes of work with a self-evaluation and assessment period between sets is sufficient. These sessions can occur on consecutive days. Most important to note for this stage is to start with a conservative speed. Unless advised by the sports medicine practitioner, inclining the treadmill is not recommended because of the implications on the running gait. The objective of this phase is to provide and promote confidence to the athlete in unweighted, standardized conditions. The treadmill provides the athlete confidence in the surface and speed; therefore, they can focus on the mechanics and biofeedback of the body around the injury site. Intensity at this stage is not recommended to exceed 60 percent of the player's perceived maximum speed.

In these early phases we are trying to reteach the brain and muscle coordination pattern, which has been altered because of the injury. The healing process will, in theory, repair the site of the injury, most likely to its original form. Always be prepared to present a conservative exercise or rehabilitation and training environment that offers the athlete a great potential of success, then look to increase volume, intensity, and complexity.