-------------- [ CLINICAL COMMENTARY ] --------------

M A TTH EW BUCKTHORPE, PhD1 • FRANCESCO DELLA VILLA , MD1 • STEFANO DELLA VILLA , MD1 » G IU LIO SERGIO ROI, MD1

On-field Rehabilitation Part 2:

A 5-Stage Program for the Soccer
Player Focused on Linear Movements,
Multidirectional Movements, Soccer-
Specific Skills, Soccer-Specific
Movements, and Modified Practice
n part l,6 we described 4 pillars underpinning high-quality tion during the transition back

I on-field rehabilitation: (1) restoring movement quality, (2) to sport.

physical conditioning, (3) restoring sport-specific skills, On-field rehabilitation repre­
sents the period when the player
and (4) progressively developing chronic training load. In
is transitioning from gym-based
part 2, we describe how these pillars contribute to a 5-stage
rehabilitation to the com peti­
on-field rehabilitation program to help injured players transition tive team environm ent.6'7'9 Overall, the
to team practice and match play. We explain this program using an transition process can be considered a
example case of a soccer player with ambi­ stand (1) where on-field rehabilitation continuum (F IG U R E 1 ) of on-field reha­
tions to return to sport (RTS) after anteri­ fits within the overall recovery process, bilitation, safe resum ption of full-team
or cruciate ligament (ACL) reconstruction. and (2) whether the player has sufficient training, and gradual reintroduction
fitness to RTS practice. A prospective to full competitive match play.7 Players
H o w D o e s O n -fie ld R e h a b ilita tio n study found that 4% of elite-level soccer on European Champions League teams
F it W ith R T S ? players with ACL reconstruction sus­ returned to practice at 202 days after
W hen planning high-quality on-field tain a graft rupture prior to their first ACL reconstruction, on average. Play­
rehabilitation, it is necessary to under­ m atch,16 highlighting the need for cau­ ers returned to competitive match play
at 225 days,16 leaving only 23 days be­
• S Y N O P S ! T h is p a p e r is p a rt 2 of a 2 -p a r t T h e p ro g ra m m o v e s th ro u g h 5 fie ld -b a s e d tra in in g tween finishing rehabilitation and play­
s erie s a im e d a t d is c u s s in g th e key e le m e n ts of stag es: (1 ) lin e a r m o v e m e n t, ( 2 ) m u ltid ire c tio n a l ing a m atch to prepare for high-level
o n -fie ld re h a b ilita tio n tra in in g . In p a rt 1, w e d e ­ m o v e m e n t, ( 3 ) s o c c e r-s p e c ific te c h n ic a l skills, ( 4 ) competition. Twenty-three days is un­
s c rib e d 4 p illa rs u n d e rp in n in g h ig h -q u a lity o n -fie ld s o c c e r-s p e c ific m o v e m e n t, a n d ( 5 ) p ra c tic e s im u ­ likely to be long enough to adequately
re h a b ilita tio n : (1 ) re s to rin g m o v e m e n t q u a lity, ( 2 ) la tio n . T h e s ta g e d p ro g ra m is re s e a rc h b a s e d a n d prepare a player physically, technically,
p h y sic al c o n d itio n in g , ( 3 ) re s to rin g s p o rt-s p e c ific fa c ilita te s c o m m u n ic a tio n , p la n n in g , c o n tro l, a n d
s kills , a n d ( 4 ) p ro g res s iv e ly d e v e lo p in g c h ro n ic
tactically, and psychologically for com­
s a fe ty in re tu rn to s p o rt fo llo w in g lo n g -te rm injury.
tra in in g lo a d . In p a rt 2 , w e d e s c rib e h ow th e p illars petitive match play after 202 days away
J O rthop Sports Phys Ther 2 0 1 9 ;4 9 (8 ):5 7 0 -5 7 5 .
c o n trib u te to a 5 -s ta g e o n -fie ld re h a b ilita tio n
Epub xxx. d o i:10 .2 5 1 9/jo s p t.2 0 19 .8 9 5 2
from the soccer pitch. This might be one
p ro g ra m to h elp in ju re d p la ye rs tra n s itio n to te a m of the reasons why 4% of players suffer
p ra c tic e a n d m a tc h play. W e use th e e x a m p le of • KE Y W O R D S : criterio n -b ased rehabilitation,
ACL graft rupture before the first match,
a s o c c e r p la y e r w ith a m b itio n s to re tu rn to s p o rt o n -field rehab ilitation , p erfo rm a n c e rehabilitation,
a fte r a n te rio r c ru c ia te lig a m e n t re c o n s tru c tio n . reconditioning, return to sp o rt
and 3% soon after the return-to-play pe­
riod (less than 3 m onths).16

‘Isokinetic M ed ical G roup, Education and R esearch D e p a rtm e n t, FIFA M edical C entre of Excellence, B ologna, Italy. The auth ors c ertify th a t th ey have no affiliations w ith or
financial in volvem ent in any organization o r entity w ith a direct financial interest in th e sub ject m a tte r o r m a terials discussed in the article. A ddress co rrespo nd ence to D r
M a tth ew B u ckthorpe, Isokinetic M edical G roup, 11 H arley S treet, London W IG 9P F UK. E-m ail: M .B ucktho rpe@ iso kinetic.co m > C opyright © 2 0 1 9 Journal of Orthopaedic &
Sports Physical Therapy ®

570 I AUGUST 2019 I VOLUME 49 | NUMBER 8 | JOURNAL OF ORTHOPAEDIC Etf SPORTS PHYSICAL THERAPY
 An extended period of RTS prepara­
tion might help injured players safely re­
turn to play after ACL reconstruction. We
propose 5 stages of on-field rehabilita­
tion,6 followed by a progressive return to
team practice and gradual return to com­
petitive match play. The player can focus
on regaining soccer-specific movement,
with physical, technical, and tactical per­
formance and psychological readiness to
perform.
Given the high-intensity physical
demands of on-field rehabilitation, the
player requires sufficient lower-limb
strength (quadriceps, hamstrings, glu-
teals), movement control in foundation
tasks and running, and adequate aerobic
and anaerobic fitness.14
We suggest the player meet the follow­
ing criteria prior to commencing on-field
rehabilitation following ACL reconstruc­
tion: (1) no knee pain or swelling,9 (2) no
subjective knee instability,9 (3) negative
knee laxity tests,3'9 (4) a minimum of 80%
limb symmetry during isokinetic assess­
ment of knee flexor and extensor strength
(100% limb symmetry before discharge
from on-field rehabilitation),9 (5) good
movement quality (ideally, assessed
qualitatively with video analysis) in ba­
sic foundation movement exercises,3 and
(6) ability to run aerobically (ie, without
blood lactate accumulation) for greater
than 10 minutes at 8 km /h with suffi­
ciently normalized running mechanics
(ideally, assessed qualitatively with video
analysis).9
Progression should be based on the
criteria described in TABLE 1. On-field re­
habilitation should be completed along­
side additional gym-based strength and
conditioning and movement retraining.
5 Stages of High-Quality
On-field Rehabilitation
Effective on-field rehabilitation is charac­
terized by a structured approach to plan­
ning and managing variation in training
load. A consistent increase in training
load underpins an increase in the body’s
capacity to do work.5 Training load can
be progressed by changing volume (the
quantity of activity performed), inten­
sity (the qualitative component of the
exercise), and frequency (the number of
sessions in a period of time) of training,5
based on the player’s capacities and needs.
We recommend the rehabilitation
clinician use a global positioning system
(GPS), which can provide a valid m ea­
sure of external workload,8 to quantify
on-field rehabilitation training load. For
soccer players, we m onitor 7 metrics,
which provide a relatively simple but
complete and reliable picture of the
workload demands of soccer (TABLE 2 ):
total distance walked/run in a session,
peak running speed, high-speed running
distance (at speeds greater than 19.8
km /h), sprint distance (at speeds great­
er than 25 km /h), total acceleration dis­
tance, total deceleration distance (with
acceleration/deceleration greater than
+3 m /s2), and time in the aerobic and
anaerobic heart-rate zones. We calculate
heart-rate zones as either (1) heart rate at
lactate thresholds, measured during an
incremental running test, with thresh­
olds of 2 mm ol/L and 4 mmol/L for
aerobic and anaerobic zones, respective­
ly11; or (2) arbitrary heart-rate zones (ie,
aerobic zone at 70% to 85% of maximal
heart rate and anaerobic zone at greater
than 85 % of maximal heart rate).1We use
the GPS and heart-rate metrics to objec­
tively support transitions through on­
field rehabilitation, which fits between
gym-based rehabilitation and return to
training with the team (FIGURE 2 ).
Stage 1: Linear Movement The aim of
stage 1 is to transition to the field, to pre­
pare physically and mentally for increas­
ing sport-specific demands.
R ehabilitation phases OFR RTT RTC RTP
FIGURE 1. A RTS process involving a gradual transition
from rehabilitation to performance training and a
continuum of OFR, RTT, RTC, and RTP. Abbreviations:
OFR, on-field rehabilitation; RTC, return to competitive
match play; RTP, return to performance; RTS, return to
sport; RTT, return to training, Modified with permission
from Buckthorpe et al.7

Gym -based (indoor) Return to tra inin g w ith

rehabilitation the team

Continue indoor-based strength, conditioning, and m ovem ent

tra inin g /re tra in ing

© Pain > 2 /1 0 on NRS © No pain

Increase in swelling No swelling
U nsatisfactory progression S atisfactory progression

FIGURE 2. Timeline following anterior cruciate ligament reconstruction. On-field rehabilitation fits between indoor rehabilitation and return to training with the team and is
subdivided into 5 stages. During OFR, indoor training can continue. Pain greater than 2/10 on an NRS, an increase in swelling, and/or unsatisfactory progression should trigger
regression to the previous stage. Abbreviations: NRS, numeric rating scale; OFR, on-field rehabilitation.

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 [ CLINICAL COMMENTARY }

F iv e S tages o f O n - f ie l d R e h a b il it a t io n , W it h t h e O v era ll F ocus f o r E ach

TABLE 1 I
S tage , t h e Ty pe o f A ctivity , a n d S p e c if ic E x a m pl e s o f C o n t e n t

■ On-field Rehabilitation Program

Stage 1
Specific entry criteria No pain or swelling
No subjective instability
No positive laxity tests19
Symmetrical ROM
Knee flexor and extensor
LSI >80%9
Ability to run at 8 km/h
for 10 min with sufficiently
normalized running me­
chanics9
Sufficient movement
quality during foundation
movements
Goal of stage Linear movement coaching • Multidirectional movement
coaching
On-field activity
Movement Linear running (forward
and lateral)
Foundation movement
tasks (eg, squatting, lung-
ing, athletic walks)
Deceleration tasks in
preplanned situations of
differing velocities
Mobility drills
Stage 2
No pain or swelling
Satisfactory progression
through stage 1 on-field
activity
• Increased speeds of move-
ments from stage 1
• Multidirectional
preplanned coordination
drills (eg, cutting drills at
increasing angles, curved
running drills, figure-of-
eight drills, accelerations,
decelerations)
Stage 3
• No pain or swelling
• Knee flexor and extensor
LSI >90%
• Optimal movement quality
during preplanned sport-
type tasks
• Satisfactory progression
through stage 2 on-field
activity
• Soccer technical and reac-
tive movement training
• Maximum-speed
preplanned linear and
multidirectional movement
drills (change-of-direction
drills, peak running speed
exposure, ladder drills)
• Reactive movement
retraining: high-speed mul-
tidirectional preplanned
speed, acceleration, and
deceleration training
(closed tasks) and
movement practice
under external focus with
technical-based drills
Stage4 Stage 5
No pain or swelling • No pain or swelling
Satisfactory progression • Satisfactory progression
through stage 3 on-field through stage 4 on-field
activity activity
• Soccer-specific movement • Training simulation/fecon-
and skill restoration ditioning
Continued preplanned • Soccer-specific movement
and reactive movement training: soccer-specific
training: high-speed mul- plus speed and agility
tidirectional preplanned training in preplanned and
and reactive movements, reactive tasks, with and
movement in soccer- without fatigue
specific situations, closed
soccer-specific fitness
drills (eg, stage 3 soccer
movement drills for con-
ditioning), repeated sprint
running
Reactive movement train­
ing with perturbations (eg,
ropes; Swiss ball; agility
circuit with ropes, Swiss
balls, player contact)
Technical drills with pres­
sure, contact to force the
player off balance
Table continues on page 573.

We start with simple movement drills
involving discrete linear tasks.3,9 Mul­
tidirectional movements and higher
movement speeds place greater load on
the knee, so it is im portant to gradually
increase movement speeds13 and com­
plexity.2,17 Keeping the sessions short and
focusing on restoring movement quality
(pillar 1 of on-field rehabilitation) are the
starting points of stage l.s We minimize
soccer-specific activity (with the soccer
ball) to reduce movement variability and
possible exposure to “high-risk” scenarios
(eg, reacting by reaching for an unexpect­
ed bad pass). However, players are al­
lowed and should be encouraged to have
very “controlled” activity with the soccer
ball (eg, “keep-ups,” touches between the
inside of the feet, and standing/predict-
able volleys or passes).
There is an increase in training load
once a player commences on-field reha­
bilitation. Therefore, we prioritize load
for high-quality movement retraining.
In the gym, it is possible to use addi­
tional non-weight-bearing cardiovascu­
lar training (eg, interval-based training
on the bike or cross-trainer) to develop
cardiovascular fitness while limiting knee
load. Key movement tasks must include
unidirectional forward and lateral run­
ning drills at self-selected speeds and
controlled accelerations and decelera­
tions during these movements (TABLE 1,
ONLINE VIDEO 1).
Stage 2: Multidirectional Movement The
aim of stage 2 is to execute preplanned
multidirectional movements at or near
full speed and without poor biomechan-

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 Five Stages of O n - field Rehabilitation , W ith the Overall Focus for Each
Stage, the Type of A ctivity, and Specific E xamples of Content (continued )

O n - fie ld R e h a b ilita tio n P ro g ra m

1

S tage 1 S tage 2 S tage 3 S tage 4 Stage 5

P h y s ic a l • A e r o b ic c o n d it io n in g • A e r o b ic c o n d it io n in g u s in g • L in e a r c o n t in u o u s o r A e r o b ic a n d a n a e r o b ic • A e r o b ic a n d a n a e r o b ic ( 1 5 -

a c h ie v e d d u r in g r u n n in g in t e r v a l- b a s e d r u n n in g in te r v a l- b a s e d r u n n in g f o r c o n d it io n in g ( > 1 5 m in 2 0 m in a b o v e A T ) d u r in g

( 1 0 - 2 0 m in ) a e r o b ic a n d a n a e r o b ic (1 2 a b o v e A T ) d u r in g a g ilit y s o c c e r - s p e c if ic a c t iv it y (e g ,

• H ig h - s p e e d r u n n in g m in a b o v e A T ) ; p e a k lin e a r a n d s o c c e r - s p e c if ic s it u a ­ p o s s e s s io n d r i lls , s o c c e r

e x p o s u re r u n n in g s p e e d e x p o s u r e t io n s c ir c u it s )

T e c h n ic a l / t a c t i c a 1 • S im p le t e c h n i c a l d r i lls s u c h • E a s y s o c c e r t e c h n ic a l ■ S o c c e r t e c h n ic a l p r o g r a m : • S o c c e r s k ills p r o g r a m : • S o c c e r - s p e c if ic t r a in in g :

a s “ k e e p - u p s ," to u c h e s d r i lls w it h k n e e c o n t r o l in t e c h n i c a l d r i lls ( p r e p la n n e d a c t iv it ie s f r o m s ta g e 3 , w it h s o c c e r s im u la t i o n t r a in in g

b e tw e e n t h e in s id e o f t h e s t a n d i n g p o s it io n : s ta n d i n g c lo s e d t a s k s ) o f in c r e a s in g p r e s s u r e a n d / o r a t h ig h e r in r e a lis tic d r i lls a n d s it u a ­

f e e t, a n d s t a n d i n g / p r e d ic t - v o lle y s , s im p le p a s s e s , d if f ic u lt y ( p a s s in g : s h o r t to s p e e d s a n d w it h g r e a te r t io n s , c o n t a c t i n t r o d u c t io n

a b le v o lle y s /p a s s e s m a i n t a in in g b a la n c e , a n d lo n g , t o u c h w o r k , c r o s s in g , n u m b e r o f d e c is io n s ; a t t h e n e c e s s a r y in t e n s it y

o p t im a l lim b c o n t r o l a n d s h o o tin g ) i n t r o d u c t io n t o 1 - v e r s u s - l

a n d 2 - v e r s u s - l d r ills in

in c r e a s in g ly v a r ie d g a m e s

( w it h n o c o n t a c t / l i g h t

t a c k lin g )

L o a d in g ( s e e • I n t r o d u c t io n t o o u t fi e l d • D e v e lo p t o t a l r u n n in g • E x p o s u r e t o s p r i n t r u n n in g • A p p r o a c h t r a in in g in te n s ity • M im ic t h e p h y s ic a l lo a d in g

TABLE 2) a c t iv it y : e x p o s u r e t o r u n ­ d is t a n c e s t h r e s h o ld s d e m a n d s o f t e a m t r a in in g

n in g v o lu m e ( 3 - 4 k m ) • E x p o s u r e t o h ig h - s p e e d • D e v e lo p v o lu m e in a ll a r e a s • D e v e lo p c h r o n ic lo a d in g

lin e a r a c c e le r a tio n s ,

d e c e le r a t io n s , a n d r u n n in g

speeds

Abbreviations: AT, anaerobic threshold; LSI, limb sym m etry index; ROM, range o f motion.

ics or hesitation. Once the player can do tioning (linear running only), using ef­ “reactive movements.” Technical training
this, he or she can commence soccer- fective work-to-rest ratios to specifically involves practice of preplanned soccer-
specific practice, with focus on move­ target energy system development, is specific drills (eg, control the ball and
ment coaching/coordination training, also appropriate. Simple soccer drills pass to the player on your right), with
and progress to preplanned multidirec­ can be practiced during controlled tasks no pressure from other players. Techni­
tional movements of increasing speed (eg, straight-line dribbling, controlled cal elements can be progressively added
and complexity.2,15,17 volleying, simple passing drills). Linear to linear and multidirectional movement
Movements practiced in stage 1 can movement drills can be performed with tasks practiced in stage 2 to add speci­
be performed at higher speeds (eg, high­ a task goal (eg, forward and backward ficity (eg, external focus of attention
speed linear running, accelerations, and running with a controlled volley/pass with greater neurocognitive demands).
decelerations). Then, the player can exercise) (TABLE 1, ONLINE VIDEO 2 ). Reactive-movement training involves
progress through increasingly more Transition to stage 3 is criterion based performing movements such as cutting
complex change-of-direction drills, (TABLE 2 ) to ensure the player is well-pre­ while reacting to an external stimulus
gradually reducing task constraints and pared for soccer-specific training (eg, (eg, running forward and changing di­
progressively increasing the intensity technical training, soccer-specific move­ rection at the cone, either right or left,
of accelerations and decelerations (eg, ment drills). depending on how the player reacts to
progress from 2 m/s2 to 3.5 m/s2). The Stage 3: Soccer-Specific Technical the cue presented immediately before
GPS can confirm when the player is able Skills The aim of stage 3 is to complete the required task).
to complete the metrics of these tasks the technical soccer program and train Reactive movements can challenge
at the desired movement intensity (eg, “agility” (movement with reactive deci­ biomechanics and increase knee loads
achieve near peak decelerations and the sion making).13 more than planned movements.2 Thus,
planned volume of accelerations and de­ The player commences more intense delaying reactive movement training
celerations in excess of ±2 m/s2). Linear soccer-specific practice. In stage 3, the until the player has achieved safe biome­
running speed can increase (eg, greater focus is on progression through a soccer- chanics in preplanned tasks and restor­
than 25 km/h); cardiovascular condi­ specific technical program and training ing and confirming safe biomechanics

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 [ C L IN IC A L C O M M E N T A R Y ]

training also provides a cognitive stimu­

An E x a m ple of P r o g r e ssiv e Lo a d in g and
M a n a g e m e n t D u r in g t h e 5 Stages of O n - f ie l d
R e h a b i l i t a t i o n f o r a n E l i t e S o c c e r P la y er
P r i o r t o R T S A f t e r A CL R e c o n s t r u c t i o n *
Stage
1 2 3 4 5 speeds during running and acceleration
S essions, n 3-5 3-5 3 -5 4 -6 4 -6
Peak speed, k m /h 17-21 22 -25 28+ 30+ 30+
Total dista nce, m 3 0 0 0 -4 5 0 0 4 0 0 0 -5 0 0 0 4000+ 4500+ 4500+
HSR d is ta n c e ,, m* 0-1 0 0 10 0+ 2 0 0 -4 0 0 500 4 0 0 -8 0 0
S p rin t dista nce, m ‘ 0 50 100 150+ 1 0 0 -3 0 0
C o m b in e d a cce le ratio n and 0 -5 5 80+ 1 0 0 -2 0 0 >250 >300
d e c elera tion dista nce, m 5
HR a t 7 0 % to 8 5 % o f m axi- 0-10 10-20 30 2 0 -3 0 2 0 -3 0
m u m , m in
HR a t > 8 5 % o f m a xim u m , m in 0 0 -5 15 15-20 20+
Abbreviations: ACL, anterior cruciate ligament; HR, heart rate; HSR, high-speed running; RTS,
return to sport.
*Seven key metrics are adopted, with progression through stages based on achieving the desired inten­
sity and quality o f work, alongside other rehabilitation criteria (eg, movement quality, psychological
readiness, strength and power, no p a in or swelling).
Defined as 20 to 2 5 km /h.
:Defined as greater than 25 km /h.
8Defined as greater than ±3 m /s2.
in reactive movements prior to RTS are practice intensity (eg, 85%-90%), includ­
crucial aspects of this stage of the on-field ing l-versus-1 drills under match-type
rehabilitation process. scenarios (eg, a goal) and controlled con­
Physical therapists should train tech­ tact practice (eg, light contact for confi­
nical drills and reactive movements dence, perturbation training in l-versus-1
separately, prior to progressing to skills situations).
training. Skills training involves perform­ Training neuromuscular control in
ing soccer-specific drills, either under soccer-specific movements and during
pressure from an opponent or during skill-based training sessions helps the
open tasks (involving greater choices and player prepare for safe participation in
environmental stimuli), and typically re­ soccer. To do this, a program of progres­
quires reactive movements, quick deci­ sive sport-specific movements must be
sion making, and less control. created to support the transfer of move­
In stage 3, physical therapists should ment patterns into sport-specific scenari­
progressively increase training load and os. This includes a gradual progression to
cardiovascular conditioning of the athlete more challenging tasks at higher speeds
on the field to develop the player’s physi­ and with more challenging visuomotor
cal fitness, limit/avoid fatigue during requirements (eg, a greater num ber of
complex movement tasks, and improve choices),13 so the player must progres­
performance and avoid poor biomechan- sively become able to safely execute high­
ics.4,6,10Movements trained in stage 2 may speed multidirectional movement drills
now be performed at maximal speed to while fatigued.
develop anaerobic performances (eg, Physical therapists should use soccer-
speed training) (TABLE 1, ONLINE VIDEO 3). specific fitness drills to train technique
Stage 4: Soccer-Specific Movements The development, with simultaneous car­
aim of stage 4 is to progress toward team diovascular conditioning. Soccer fitness
lus, challenging the technical aspects
under fatigue as preparation for return
to unrestricted team practice. Physical
therapists should monitor workload dur­
ing these tasks, assessing the GPS m et­
rics in detail to ensure that the desired
and deceleration thresholds and the de­
sired cardiovascular stress (eg, average
heart rate and minutes at an intensity
of greater than 85% of maximum) are
achieved (TABLE 1, ONLINE VIDEO 4 ).
Stage 5: Practice Simulation The aim of
stage 5 is to prepare for return to unre­
stricted practice with the team by creat­
ing a practice environment that mimics
the physical, technical, and psychological
loading demands of the sport.
Stage 5 aims to bridge the gap be­
tween on-field rehabilitation and unre­
stricted team practice. During this stage,
the player can participate in modified
team practice (eg, join in the warm-up
and technical skills sessions), where un­
injured players are enlisted to replicate
the soccer practice environment (eg, have
an uninjured goalkeeper help with shoot­
ing practice; 1 or 2 players for possession
or drill activities, such as crossing and/
or finishing). Emphasize group-based
technical and tactical drills, including
possession drills in 1-versus-I and 2-ver-
sus-2 situations.
M onitor load progression (intensity
and volume) using a GPS (or other load­
monitoring system) to ensure the correct
stim ulus for adaptation and develop­
ment of chronic training load (TABLE 2 ) .12
The player’s key load metrics m ust be
achieved during soccer-specific activ­
ity (eg, soccer fitness drills, possession
scenarios, skills practice) and not during
supplementary activity (eg, end-of-ses-
sion runs). The exception may be high-
intensity/sprint running, which may be
difficult to achieve in some types of soc­
cer practice (eg, small-sided games) and
may require additional high-intensity/
sprint sessions. The player must perform
at a minimum of 90% of the required
practice intensity and complete at least

574 I AUGUST 2 0 1 9 I VOLUME 4 9 | NUMBER 8 | JOURNAL OF ORTHOPAEDIC & SPORTS PHYSICAL THERAPY
90% of the preinjury training volume (or
relative to a normative value where pre­
injury data are unavailable). In addition,
the soccer player should have reached at
least 70% of the preinjury chronic train­
ing load (or relative to normative values)
in all relevant physical workload metrics
(TABLES 1 and 2).
Criteria for return to unrestricted
team practice7 include clinical (pain,
swelling, stability/laxity, range of mo­
tion), functional (strength, endurance,
body composition), biomechanical
(movement analysis testing), psycho­
logical (fear of reinjury, confidence),
and sport-specific (ability to support
volumes and work intensities in train­
ing, sport-specific physiological screen­
ing) factors.
Summary
We focus on 4 pillars of high-quality on­
field rehabilitation when helping players
transition back to sport after long-term
injury: restoring movement quality,
physical conditioning, restoring sport-
specific skills, and progressively devel­
oping chronic training load.6 A 5-stage
program, focused first on coaching linear
movements and subsequently on multidi­
rectional movements, then on restoring
soccer-specific technical skills and move­
ments and reaching practice simulation
before return to usual team activities,
may help rehabilitation clinicians and
players communicate, plan, and execute
a safe RTS. •
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