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Getting Back into the Game

Returning a player to sport after an injury can be challenging. After a prolonged absence, players can often be deconditioned and as a result, can be prone to either re-injury or sustaining a new (different) injury. Ideally, the return to play (RTP) involves a progressive rehabilitation process designed to return them to their pre-injury level of function (or better) before retaking the field. At all times the player's welfare and safety needs to be front of mind. The player should be involved in the process throughout and should be aware of time frames, goals, and criteria for progression from each stage. Regular reviews, re-education, and troubleshooting are essential.

While injured, players need to cross-train to keep as much fitness as possible. This is started as soon as practically possible after their injury. Cycling, grinding, seated boxing, swimming, deep water running or (in professional sport) an altered-G treadmill can all be used.

The key concept with return to play is a steady, planned progression from injured to well. This progression will occur concurrently across multiple areas. For lower limb injuries it may begin with the player non-weight bearing on crutches, with a slow return to weight bearing, followed by walking, jogging, running and finally sprinting. Sprinting is then often targeted to sport specific demands progressing rapid accelerations and decelerations, stepping and cutting, and longer maximal efforts. At the same time total mileage, or endurance, will steadily be increased.

While the return to running is occurring, a progressive program aimed at restoring (or improving) muscle strength and endurance will also occur. This can begin with resistance free movements (such as pendulums for a shoulder injury), and then low weight or isometric exercises (holding against light resistance without moving). Gradually more challenging strength work will begin, moving to heavier weights, and incorporating eccentric or rapid power based movements. The end of this stage will challenge the muscles maximally with full strength lifts, rapid catch and hold movements, and sport specific strength work (such as scrum position work for front rowers). Range of motion exercises (stretching) stability and balance training will also be progressed at this time.

This progressive return to play process works best when accurately and objectively measured. In a professional (or elite) environment, GPS units allow real-time breakdown of distance and speeds achieved. Force plates, dynamometers and other measuring units allow quantification of strength and power. These are compared to the uninjured side, and to pre-injury baselines, to allow accurate prescription of the rehabilitation and a measure of progress.

Once predetermined criteria are achieved players can then be re-integrated into sports-specific and team training. This is done on a drill-by-drill basis, often initially avoiding contact or uncontrolled free-play type drills. These restrictions are then steadily reduced until the player is training fully, and deemed available for selection. Coaching staff will then usually have further technical/tactical criteria, and a demonstration of match fitness, so often return occurs at a lower level or team if this is available.

It is important not to forget the rest of the body during rehabilitation. Secondary injuries (for example straining a hamstring when coming back from a shoulder reconstruction) are hugely frustrating. Continuing other strength and rehabilitation/prehabilitation work during the injured phase, and following a tightly controlled graduated progression, reduces this risk. An injury also provides an opportunity to target ‘work-ons’ (areas of perceived physical, tactical or technical weakness) and this should be taken. Core strength, general flexibility and proprioception are some areas that almost any injured player could work on. Involvement in team tactics, or game review, or mentoring of more junior players should all be considered to keep the player involved mentally.

Once the player has returned to play, rehabilitation will still need to continue. Often return to play can occur once a limb injury is within 90% function of the other side. The last few percent needs to be regained through ongoing diligence, in order to reduce the risk of re-injury.