Knee Injuries in Professional Football and Elite Sport – Injury Rehab Network Event

Sterosport and Football Fitness Federation were pleased to work together to bring a unique CPD event to football fitness and sports rehabilitation professionals. The event at UA92 in Manchester on 27^th April from 6pm – 8pm featured presentations from expert guest speakers Cristian Fernández and Dr Lee Herrington.

This in-person event was delivered in partnership with Football Fitness Federation with 40 people joining the session. Practitioners from sports teams across the UK attended together with staff and students from UA92.

Recordings of the presentations are available on the Football Fitness Federation website. 

Expert guest speakers

Cristian Fernández, Rehab Fitness Coach

Cristian Fernández is currently working as a consultant in injury prevention and rehabilitation in football. He has worked in professional football as a Rehab Fitness Coach at Everton FC, Newcastle FC, Hull City AFC and Northampton Town FC.

Cristian’s education has focused on physical activity and injury prevention, including:

• MSc Injury Prevention and Rehabilitation in Football. RFEF – Royal Spanish Football Federation. 2015,
• MSc Research in Physical Activity, Sport and Health (2011. University of Vigo)
• Degree in Sports Science (2010, University of A Coruña)

He is a lecturer in Injury Prevention and Rehabilitation in Football with the Spanish Fitness Coaches Association and Royal Madrid Football Federation, where he speaks about the following subjects:

• “Treatment and management of chronic injuries in football”
• “De-training and conditioning during the rehabilitation process”
• “Rehabilitation in Acute Muscle Injuries: Groin.”

Dr Lee Herrington, University of Salford

Dr Lee Herrington @leehphysio, Physiotherapist and Senior Lecturer in Sports Rehabilitation, Salford University; programme leader for the MSc Sports Injury Rehabilitation course. Lee is a Technical Lead Physiotherapist with the English Institute of Sport, leading on issues related to lower limb injury rehabilitation across all the Olympic & Paralympic sports. Dr Herrington also acts as a consultant physiotherapist to Premiership & Championship Football and Rugby Union clubs.

Lee worked as part of Team GB’s medical team at the London 2012 and Rio 2016 Olympic Games and has previously worked with British Swimming, Great Britain Basketball Team, Wigan Warriors, and Great Britain Rugby League teams along with England Table Tennis and Netball.

He is the lead Clinical Researcher in the Knee Biomechanics and Injury research programme at Salford University. Specific research interests are anterior knee pain and rehabilitation following knee surgery (principally ACLR) and Lee has published over 200 peer-reviewed papers. Lee is the editor in chief of Physical Therapy in Sport and on the editorial board of The Knee Journal and Journal of Sports Rehabilitation.

Recordings of the presentations are available on the Football Fitness Federation website. 

Its not all about ball work; early-stage rehab for knee injuries

Dr Lee Herrington’s presentation considered early-stage rehab for knee injuries. A great deal of emphasis is put on late-stage & return to sport player rehabilitation after knee injuries, but this is likely to be sub-optimal unless it has built a strong foundation of tissue resilience and physical qualities required.

This talk discussed the key elements of early-stage rehabilitation required to build tissue resilience and develop the physical qualities required to move into more sport-specific training. Specifically covering how to monitor & develop tissue load tolerance; pillars of rehabilitation including the development of maximum force & force-velocity, load acceptance & the ability to decelerate, along with early movement skill development.

Dr Lee Herrington

Dr Herrington is a Senior Lecturer in Sports Injury Rehabilitation University of Salford, Athlete Health Lead, English Institute of Sport and Editor in Chief, Physical Therapy in Sport.

Early-stage rehab for knee injuries

Lee provided an introduction to early-stage rehab for knee injuries and discussed the position of early-stage rehab in the return to sport continuum where the focus is to enable return to participation. As athletes prepare to participate in training following injury, practitioners should consider local tissue load tolerance and the response to load and recovery. Dr Herrington considered the loads that the injured tissue needs to tolerate and the load the tissue can tolerate. The ACL can withstand a force over 2,000N.

Lee discussed the requirement for load progression in rehabilitation and how isometric force tests can be useful with ‘make’ and ‘break’ variations. He also discussed some of the considerations around movement including ground reaction force, planes of movement, repetitions, and constrained vs unconstrained exercises. Lee encouraged practitioners to consider ‘What can the tissue cope with at this moment in time?’

In the initial stages of knee rehab, simple measures such as step counts and on feet time may be effective ways to monitor activity levels and progress.

Lee asked the question, “How do you know the tissue is tolerating the load?” and encouraged practitioners to monitor tolerance to load with signs of excess stress including pain, swelling, stiffness and muscle inhibition.

Strength and knee injury rehab

Dr Herrington discussed strength in the context of knee injury rehab where there is truth in the saying “You can’t go wrong with getting strong” but athletes can potentially waste time in an attempt to get too strong. Lee discussed five fundamental tests to predict elevated risk, including:

1. Single hop for distance
2. Anterior reach
3. Isometric hip abduction
4. Bilateral back squat
5. Isometric quads strength

Lee dispelled some myths in relation to hamstrings and quads strength ratio as due to the variations in eccentric and concentric strength it is not possible to have a neat ratio. Strength training should focus on building the rate of force development with exercises including mid-thigh pulls and sled pushes and pulls. Dr Herrington discussed horizontal and vertical force generation and how a range of jump exercises can be an effective part of knee injury rehabilitation.

Movement skill

Lee discussed movement skills or neuromuscular control including static stability, control under load, running, landing, acceleration/ deceleration, and change of direction. Practitioners can use visual analysis to assess the progress of athletes during exercises such as squat jumps and Lee described how asymmetry may be clear as athletes attempt to complete these exercises.

Lee considered how acceptable load can be built following a knee injury with progressions through bilateral landing, bilateral plyometric, unilateral landing and finally unilateral plyometric.

Dr Herrington described research (Gokeler et al 2020) which considered how athletic injuries are not only associated with physical impairments & poor movement competence but also perceptual-cognitive alterations.

Lee discussed the differences between closed skills which can be practised in a controlled environment and open skills which are required in a match environment. For example, a golf driving range provides an opportunity to practice closed skills whereas a golf course forces the golfer to use open skills as each shot is required and the environment is distinctly different. Closed skills enable athletes to develop physical qualities, open skills develop movement competency, and random open skills develop perceptual-cognitive control. Practitioners can therefore build progressions for knee injury rehabilitation from closed skills to open skills with randomisation.

Building running capability

Dr Herrington discussed the importance of building running capability through speed and shifting loads, treadmill (including anti-gravity) vs over ground, high-speed running volume and building chronic capacity. Lee also discussed the need to build the ability to decelerate with the need to focus on the development of a good technique to build strength and reduce future injury risk.

It was described how as athletes return to unstructured training, practitioners should take a holistic view of chronic load capacity, force generation, running speed and agility and contextual movement skill with consideration given to psychological wellbeing and physiological robustness.

Key points for early knee rehabilitation

Lee summarised his presentation with the following recommendations for practitioners:

1. Get the basics right, and the results will follow
2. Appropriate force development qualities (to performance requirements)
3. Movement skill; dual-task capability
4. Chronic capacity; at tissue and athlete level
5. All activity is directed to performance goals

Return to play after Patellofemoral Cartilage Injury (case study)

Cristian’s presentation provided a case study about the return to play following knee cartilage injury.

Articular cartilage injury is observed with increasing frequency in football, being one of the most frequently injured structures of the knee. Furthermore, it is known as one of the most important causes of functional disability and can lead to early degenerative changes in the knee joint during and after the player’s career.

Patellofemoral Cartilage Injury

Cristian described how articular cartilage is one of the most frequently injured knee structures, causing one of the greatest time loss and with one of the highest recurrence rates. Injuries may occur through traumatic (acute) aggressive loading or torsional movement causing the matrix structure to be ruptured and cell damage. Overuse injuries can be caused by the repetitive chronic load with progressive degradation of the articular surface and fragmentation of the collagen structure. Cristian discussed the importance of moderated training for effective rehabilitation to build cartilage thickness.

Rehabilitation after cartilage injury

Some of the influential factors in rehab and return to play from knee injury were considered, including individual characteristics, location and size of damaged cartilage and the type of surgical procedure. The methodological considerations include compression forces, co-contraction, joint stability and functional movements. As athletes progress in their rehab practitioners should consider volume, suitable exercise and player feedback.

Cristian discussed the need for practitioners to have a deep understanding of joint biomechanics and progressive loading of the tissue. Exercises should allow the player to work comfortably.

Case study – patellar cartilage damage and MCL

Cristian presented a case study of a professional football player with patellar cartilage damage and MCL. Following surgery, Cristian worked with the player through their rehabilitation and return to play. Cristian discussed the importance of understanding the player, their style and their role in the team.

The following rehab phases, objectives and progression criteria were presented:

1. Protection
2. Rehabilitation (post-surgery)
3. Readaptation
4. Re-training
5. Return to training and return to play
6. Team

Protection

In the initial protection phase, the objectives are to avoid de-training, manage pain, progress in a range of movement, recover the capacity of the quad and introduce walking patterns. Exercise may include swimming, cycling and upper body strength training.

Rehabilitation

In the rehab phase, the objectives are to gain a full range of movement, to introduce partial loading and progress to functional strength. Activities may include cycling (indoor), deep water running, cross trainer and walking (treadmill).

Readaptation

In the readaptation phase, the player will progress from jogging to running during a two-month programme. The objectives are to progress to loading flexion, recover strength level, perform high speed running, and focus on specific skills and specific movement patterns. The activity takes place on the field and in the gym and may include crash matt jogging, progression of walking/ jogging distances and basic game-based drills (dribbling and passing). Gym work includes squats and leg presses, functional strength training, core exercises and proprioceptive exercises (dynamic and with unstable surfaces).

As the player nears the end of the readaptation phase, progression should be made in running with exercises focused on the change of pace, change of direction, specific movement pattern re-learning and low impact jumping.

Re-training

Following the readaptation phase, the re-training phase may last around one month. The objectives of this phase are to optimise the fitness condition, continue to increase strength levels and test the knee’s ability to withstand repeated functional forces. Activity may include speed/ agility training, strength training, endurance training and jump re-learning.

Training includes on-field resistance methods, max speed training, aerobic power training and high intensity repeated actions. Progressions focus on attacking and defending transitions, contact situations, crossing, power shots, jumping and landing.

Team

Following re-training, the player will recommence full training with the team with objectives to optimise fitness condition and return to competition. To return to play the player should complete 4 weeks of full participation in team training sessions, participate in at least 3 U21 matches, and score more than 90% in functional testing. Importantly, there should be a consensus between the medical staff, coaching staff and players.

Load is managed through daily monitoring through GPS and heart rate monitors and daily questionnaires after sessions. Cristian described the general microcycle structure of training sessions and how this needs to be flexible based on the player’s requirements.

Conclusions

The presentation was summarised with conclusions about cartilage rehab, including:

1. It is a long term injury, and cartilage does not regenerate
2. Practitioners should have a good understanding of biomechanics, and progressive loading and seek player feedback.
3. Practitioners should try not to predispose the player to injury risk factors.
4. Rehab should focus on maintaining fitness levels.

Follow Cristian Fernández and Dr Lee Herrington

Twitter –

• Cristian Fernández @Cristian_mfm
• Dr Lee Herrington @Leehphysio

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