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case_images: The rehabilitation philosophy visualized in the 9 Phased 'Return to Performance Pathway.'. (RDLs = Roman deadlifts. IKD = Isokinetic dynamometry. COD = Change of direction. CMJ = Countermovement jump. RFD = Rate of force development. Hams = Hamstrings. Max = Maximum. Accels = Acclerations. Decels= Decelerations. GPS = Global positioning system.)
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case_images: Stage 1 was the early stage (Figure 1, gym Phases 2 and 3) where focus was placed on the player reducing pain and swelling and recovering normal gait and activities of daily living. Following this, the player went into the mid-stage (Figure 1, gym Phases 4 and 5) to regain muscular strength, power, and movement quality before entering the final sports specific stage to redevelop the underling explosive qualities and necessary soccer qualities to perform with the team. At the eight-month stage (Figure 1, grass Phase 2) despite the player completing HSR and COD drills on the grass the player felt a sharp pain in the medial aspect of the right knee during some routine hopping exercises. The aim of the first 3 phases (Figure 1) were to set the expectations and prepare the player for the loading and progressive gym Phase 4. The acute and contralateral limb loading Phase (Figure 1 - Phase 2) lasted for the first seven days post-surgery. With a low pain score (<2/10 numerical rating scale) and trace joint effusion the player progressed into the gym Phase 3 to start early loading and regain normal movement patterns (Figure 1). Firstly, it was on the grass to complete HSR (<85% of maximum speed), increase session volumes (<85% of match total volume in metres), complete reactive drills including CODs, accelerations and decelerations (<66% of match total volumes) and also to complete some longer kicking exercises (<40m) (Figure 1). By the end of week six the player had successfully completed grass Phase 2 as he had achieved the GPS criteria (Figure 1) and the necessary RFD criteria (Figure 5C) which were the prerequisites to start grass Phase 3. The aim of this phase was to achieve maximum GPS metrics (Figure 1) and work on any rehabilitation residuals that he had not accomplished. On the grass the phase involved maximum speed work (>95% of maximum speed), increased session volumes (>95% of match total volume in metres), positional drills including CODs, accelerations and decelerations (>95% of match total volumes) and also to complete positional kicking in this case namely shooting drills (Figure 1). To enter grass Phase 4 at eight weeks post-surgery the player had completed the three grass phases exposing him to the necessary GPS demands (Figure 1) and also accompanying gym profiling (Figure 5D).
case_images: Showing the 'Rehabilitation Pathways and Progressions' of gym Phase 4 and the gym exit profiling in gym Phase 5.. (IKD = Isokinetic dynamometry. Prep = Preparation. Intro = Introduction. A Skip = A skipping pattern in a linear direction emphasizing the hip drive phase of running. B skip = A skipping pattern in a linear direction emphasizing the hip extension phase of running. Alter G = Anti-gravity treadmill. RM = Repetition maximum. SL = Single leg. Reps = Repetitions.)
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case_images: Stage 1 was the early stage (Figure 1, gym Phases 2 and 3) where focus was placed on the player reducing pain and swelling and recovering normal gait and activities of daily living. At the eight-month stage (Figure 1, grass Phase 2) despite the player completing HSR and COD drills on the grass the player felt a sharp pain in the medial aspect of the right knee during some routine hopping exercises. The acute and contralateral limb loading Phase (Figure 1 - Phase 2) lasted for the first seven days post-surgery. By day 10 the player had achieved these criteria and could start the rehabilitation pathways outlined in gym Phase 4 (Figure 2). The aim of gym Phase 4 was to expose the injured lower extremity to different physical demands through the variety of rehabilitation pathways outlined in Figure 2. Having successfully completed the gym Phase 4 rehabilitation pathways described (Figure 2) he was ready to enter the gym Phase 5 (gym exit profiling). Secondly it is widely acknowledged that the power (hop test battery - Figure 4D, and countermovement jump profiling - Figure 4E) and RFD (SL drop Jump, IKD quadriceps peak torque at 0.18ms and isometric hamstring RFD at 100ms) qualities will lag at this stage, but the player had started to go through the progressions and was comfortable with all exercises of the plyometric pathway (Figure 2). Thirdly, although not purely objective, the player had completed other pathways like the running preparation and indoor ball skills (Figure 2) which further highlighted his competency in a variety of movement patterns and also to tolerate load. The development of the player s RFD had started beginning at 10 days post-surgery as the player engaged in the plyometric pathway (Figure 2).
case_images: Demonstrating the use of a daily undulating periodization plan in gym Phase 4 (Week 3 Post-Surgery).. (Prep = Preparation. IKD = Isokinetic dynamometry. Mod = Moderate. ACL = Anterior cruciate ligament. SL = Single leg. A Skip = A skipping pattern in a linear direction emphasizing the hip drive phase of running. B skip = A skipping pattern in a linear direction emphasizing the hip extension phase of running. S = Seconds.)
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case_images: Stage 1 was the early stage (Figure 1, gym Phases 2 and 3) where focus was placed on the player reducing pain and swelling and recovering normal gait and activities of daily living. During gym Phase 4 not all the rehabilitation pathways were worked on each day as a DUP theme was applied throughout the week (Figure 3). Thursdays (Figure 3). This was progressed to the land with simple landings from a step and box (altitude landings). Movement patterns through the running preparation pathway were also completed specifically on Tuesday and Fridays (Figure 3.) as the number of ground contacts increased from 100 in the first session to 600 by the end of gym Phase 4.
case_images: The data collected in six of the key rehabilitation pathways. Capacity pathway. B) Maximum strength pathway. C) IKD pathway. D) Plyometric pathway (Hop battery). E) Plyometric pathway (Force plate jumps). F) Injury specifics pathway (SL supine isometric hamstrings). (SL = Single leg. R = Right. IKD = Isokinetic dynamometry. Nm = Newton metres. Ms = milliseconds.)
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case_images: Following this, the player went into the mid-stage (Figure 1, gym Phases 4 and 5) to regain muscular strength, power, and movement quality before entering the final sports specific stage to redevelop the underling explosive qualities and necessary soccer qualities to perform with the team. The manner in which six of these progressed is highlighted in Figure 4. The maximum strength profiling (Figure 4B) saw the player achieve 230kg on a 3-repetition maximum SL leg press and 35kg each arm during a RFESS. At this stage the key criteria to achieve were >90% LSI and pre-injury scores in the peak torque at 60 /s (strength) and the total workload for 15 repetitions at 300 /s (endurance) for the quadriceps and hamstring muscles (Figure 4C). From Figure 4A, the player exceeded >90% LSI and pre-injury ipsilateral maximum scores. Scores of 67 repetitions for the SL gastrocnemius heel raise, and 80 repetitions for the hamstring bridge in 90  and the SL squat exercise were achieved (Figure 4A). Secondly it is widely acknowledged that the power (hop test battery - Figure 4D, and countermovement jump profiling - Figure 4E) and RFD (SL drop Jump, IKD quadriceps peak torque at 0.18ms and isometric hamstring RFD at 100ms) qualities will lag at this stage, but the player had started to go through the progressions and was comfortable with all exercises of the plyometric pathway (Figure 2). Also, by undertaking all of the rehabilitation pathways and achieving qualities like capacity, strength (Figure 4A) and power (Figure 4B) this could finally be accomplished. As Figure 5C highlights >90% LSI and pre-injury scores was specifically required in the SL drop jump (jump height and RSI), the RFD of the quadriceps peak torque on the IKD at 0.18ms (at 180 /s) and the isometric RFD in the hamstrings (3 x 3s isometric holds) on the force plates at 100ms (Figure 4F).
case_images: The prerequisite criteria to be achieved before the player progressed through each of the grass phases.. GYM EXIT CRITERIA Achieved Pre-Grass Phase 1 - Jogging and Re-Introductions. B) POWER CRITERIA Achieved Pre-Grass Phase 2 - HSR and COD Drills. C) RFD CRITERIA Achieved Pre-Grass Phase 3 - Maximum Speed and Positional Drills. D) ALL CRITERIA Achieved Pre-Grass Phase 4 - Training Transition. (Yellow: Maximum distance achieved in one session in metres. Ligth Blue: Maximum number of accelerations and decelerations achieved in one session. Gray: Maximum number of changes of directions achieved in one session. Dark Blue: Maximum distance of high-speed running achieved in one session (>5.7 ms-1). Red: Maximum distance of sprint metres achieved in one session (>7.3 ms-1). Maximum speed achieved in one session (ms-1). R = Right. Reps = Repetitions. Nm = Newton metres. CMJ = Countermovement jump. RSI = Reactive strength index. Ms = milliseconds. HSR = High speed running. COD = Change of direction. RFD = Rate of force development.)
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case_images: Following this, the player went into the mid-stage (Figure 1, gym Phases 4 and 5) to regain muscular strength, power, and movement quality before entering the final sports specific stage to redevelop the underling explosive qualities and necessary soccer qualities to perform with the team. Firstly, he had achieved >90% of his pre-injury ipsilateral maximum scores in his capacity, maximum strength and IKD profiling (Figure 5A). SL countermovement jump profiling. Specifically achieving >90% LSI and pre-injury scores ipsilateral maximum scores in these key power tests was required to exit grass Phase 1 (Figure 5B). SL triple hop (625cms) and the SL medial hop (152cms) both exceeding >90% LSI and pre-injury ipsilateral maximum scores (102 and 101% respectively, Figure 5B). Similarly, the SL countermovement jump height (24.2 cms) and the flight time:contraction time ratio (0.58 ms-1) for this player had achieved pre-injury levels of 94 and 95% respectively (Figure 5B). To exit grass Phase 1 the player had completed the GPS criteria (5-10m passing, low intensity COD, accels and decels, aerobic runs with a maximum of 6km in one session, all metrics <65% in speed, intensity, and volume) and also the necessary power criteria (Figure 5B) which were the prerequisites to start grass Phase 2. The second aim was in the gym where the final RFD qualities (SL drop jump, IKD quadriceps peak torque at 0.18ms and isometric hamstring RFD at 100ms) were achieved again with a prerequisite to exit grass Phase 2 being set at >90% LSI and pre-injury ipsilateral maximum scores (Figure 5C). Towards the end of the grass Phase 2 in the day 4 session the player had completed in total 91 accelerations and decelerations (57% of match total volume - Figure 5B) and 109 COD (62% of match total volume - Figure 5C). On day 5 the player accumulated 350m of HSR (peak speed 7.2ms-1 = 85% of maximum speed - Figure 5F) in this extensive day and a total of 6523m in his largest volume session (Figure 5A). As Figure 5C highlights >90% LSI and pre-injury scores was specifically required in the SL drop jump (jump height and RSI), the RFD of the quadriceps peak torque on the IKD at 0.18ms (at 180 /s) and the isometric RFD in the hamstrings (3 x 3s isometric holds) on the force plates at 100ms (Figure 4F). By the end of week six the player had successfully completed grass Phase 2 as he had achieved the GPS criteria (Figure 1) and the necessary RFD criteria (Figure 5C) which were the prerequisites to start grass Phase 3. Despite the player achieving >90% LSI and pre-injury ipsilateral maximum scores in the maximum strength (Figure 5A) and RFD profiling (Figure 5C) the player subjectively wanted to maintain these training habits and qualities. Accompanying these positives themes the player subjectively felt 90-95% ready to train (Figure 5D) which is also another key psychological prerequisite to be achieved prior to starting with the team in grass Phase 4. To enter grass Phase 4 at eight weeks post-surgery the player had completed the three grass phases exposing him to the necessary GPS demands (Figure 1) and also accompanying gym profiling (Figure 5D).
case_images: The player's GPS (global positioning system) data collected in six key metrics used to grade his exposure to soccer specific loads during grass Phases 1-4.. The maximum distance achieved in one session. B) The maximum number of accelerations and decelerations (combined) achieved in one Session. C) The maximum number of change of directions achieved in one session. D) The maximum number of high-speed running metres achieved in one session. E) The maximum number of sprint metres achieved in one session. F) The maximum running speed achieved in one session. (Accels = accelerations. Decels = Decelerations. M-s1 = Metres per second.)
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case_images: Apex, Catapult Leeds, UK) he did record some low-level (<2.5 ms-1) COD (total in one session 47, 27% of match total volume, Figure 6C) and accelerations and decelerations (total in one session 49, 31% of match total volume, Figure 6B). All these short distance intensity type actions were controlled and included within the small area (4m maximum) patterning drills the player completed. During this and simple passing drills the player regained some confidence in his body, had a reintroduction to ball drills and accumulated 18,800 meters at a low speed, with 5523m being the highest achieved in one session (Figure 6A). On the extensive days (day 2 and day 5) the player achieved a speed of 8.4 ms-1 (Figure 6F), 153m sprint meters (Figure 6E) and 580m of HSR (Figure 6D) which equated to 99%, 101% and 106% of his match metrics respectively. COD (Figure 6C) (87% and 85% respectively of match total volumes). Chaotic and highly variable movement patterns were individualized for the player through positional drills and shooting drills.