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Re: Quantifying the functional rehabilitation of injured football players

Dear Editor,

We feel the points raised in the article by Fuller et al (1) are interesting but need to be addressed from both a practical as well as an academic perspective.

From a theoretical viewpoint the concept of reaching certain performance levels in a battery of tests before a player returns to training following injury is an attractive proposition. We feel however that there are many practical considerations that make this an unworkable aim.

Although the rehabilitation following all injuries will follow the pre-functional and then functional phases the length of both these will depend on the severity of the injury, the treatment given and the player. All lateral ligament ankle sprains do not take the same length of time to recover. An experienced physiotherapist skilled in rehabilitation knows when a player has reached a stage where that player is fit to train. They will have performed a variety of routines at a rate totally dependent on the individual player. They will only have progressed when both the player and the physiotherapist have agreed that they should. Towards the end of the rehabilitation process all the exercises will be sport specific and most will be part of the normal training programme. General fitness levels, familiarisation with individual tests and weather conditions will all influence performance times hence the time when baseline measurements were taken would be critical if time taken to perform a test was taken as an absolute criteria to allow the player to progress.

To suggest that the complete absence of pain or swelling are criteria for return to play are fraught with difficuly. Any player sustaining a significant injury to the medial collateral ligament of the knee will have discomfort for many weeks following full functional recovery. Damage to the lateral ligaments of the ankle often results in some swelling which persists for a time after full functional recovery. However players with pain following a muscle strain should obviously not progress until the pain settles and the cause of a joint effusion following injury must be established before a return to training. The use of analgesia to allow a player to procede should almost never be allowed. We are not sure how in an individual case the team doctor would have been able to assess that 'tissue healing was complete'. How would he quantify 'tissue healing?'

We feel that a much better end point to the rehabilitation process is an agreement between the player and the physiotherapist that they are both happy that the point has been reached when the player is able to return to full taining. This should be entered in the medical records. If both parties do not agree, the player should not train. There will be times when a player is not fully fit but wants to play. In most circumstances following full explanation of any risks to the player by the medical team that decision should be the players. It is then the manager's decision whether the player is selected. It should never be the manager or the coach's decision whether a player can train or play. To rely totally on 'science' to make medical decisions regarding fitness to train will lose the 'art' and make sport a poorer place.

Yours sincerely

Mike Stone, MRCP, DipSportsMed, FFSEM(I).
Rob Swire, MSc, MCSP.
Neil Hough, MCSP.
John Davin, MSc, MCSP.
Richard Merron, MSC, MCSP.
Mandy Johnson, MPhil, MCSP.

Manchester United Medical Department,
Trafford Training Centre,
Carrington, Manchester,
M31 4BH.

References

1. Fuller C, Walker J. Quantifying the functional rehabilitation of injured football players. Br J Sports Med 2006;40:151-157.