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What did I do?
The primary aim of my research was to construct a conceptual framework for on-pitch rehabilitation to help guide practitioners in the Return to Sport (RTS) process following injury in elite football. I then described how the framework was used to support RTS following; a common injury (hamstring strain), a rare injury (traumatic fracture) and a severe injury (anterior cruciate ligament reconstruction (ACLR)).
Why did I do it?
Injury and re-injury are major problems in elite football.1 Inadequate rehabilitation is a risk factor for re-injury2 and football clubs strive to continually improve rehabilitation and RTS of injured players. The absence of specific frameworks to guide the on-pitch rehabilitation process was a surprising gap in the contemporary sports science literature.
How did I do it? Key elements of the control–chaos continuum
I developed an approach to rehabilitation and RTS over a decade in my roles of applied sports science and rehabilitation in the English Premier League (EPL) (figure 1). I embedded this experience and key elements of the RTS process defined in the literature into a framework for on-pitch rehabilitation. My goal was to progress the athlete from a setting of ‘high control’ to ‘high chaos’ manipulating task and environmental constraints to shape the on-pitch rehabilitation environment to the required goals. I carefully obtained the players’ running load from global positioning systems (GPS) and I progressively incorporated technical skills, greater perceptual, reactive and neurocognitive challenges (football specific actions replicating the spontaneous/unpredictable nature of sport in competition) alongside the development of physical qualities into the rehabilitation programme.3 4
I used regular strength and power diagnostic tests to support progression decisions and avoid on time-based criteria. Finally, in a series of case reports, I described a method to use preinjury GPS running load data and injury specific considerations (ie, hamstring strain; high-speed running (HSR)/HSR volume) to return the players to the required training loads to prepare them for the demands of team training/competition.
What did I find?
The ‘control–chaos continuum’ (figure 2) provides a conceptual framework to guide practitioners in the design and implementation while highlighting areas for future research for on-pitch rehabilitation and the return to required chronic running load demands after injury in elite football.4 In study 2, I presented an example of the use of the framework in the RTS of an EPL football player after hamstring injury highlighting a progressive return to HSR under increasingly chaotic conditions.5 Study 3 provided an overview of the RTS of an EPL football player following an open tibia-fracture highlighting bone-specific load considerations.6 Study 4 focused on using the conceptual framework for the RTS of an English Women’s Super League player after ACLR, highlighting the recovery of neuromuscular variables shown to display persistent deficits following this injury. Details of the progressive optimal loading applied, with consideration to the type of injury, and relevant strength and power diagnostic testing, key elements that support the framework were described in each case study. All players currently remain free of re-injury (15 months–3 years post RTS).
What is the most important clinical impact/practical application?
RTS after injury is a complex process. High-quality, individualised rehabilitation is a critical aspect — a ‘one-size’ fits all approach does not address the variability that exists between injuries, players, competitive demands and response to load. The ‘control–chaos continuum’ provides the practitioner with an adaptable framework for on-pitch rehabilitation considering both the quantitative and qualitative aspects of load. It can be adapted to the type of injury, the physical characteristics/positional requirements of the player and the stage of healing process.
I express my sincere gratitude to Dr Daniel Cohen, Professor Barry Drust, Professor Graeme Close, Dr Chris Richter and my good friend Tom Allen for helping me to bring my doctoral journey to an end without re-injury. I also thank the players within each of the studies and David Harrison, the Director of Football Operations at Everton Football Club. However, the greatest thanks are saved for my wife, Emma. The support and perspectives you provide me with not just throughout this journey but in life are priceless, you provide me with my optimal loading, a combination of strength and stability, while addressing the deficits that I possess.
Correction notice This article has been corrected since it published Online First. Figure 2 caption has been corrected.
Funding This doctoral study was funded by Everton Football Club.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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