Prehab & Rehab in Elite/ Professional Football – Injury Rehab Network Event

A partnership including Sterosport, BASRaT and UA92 worked together to bring a unique CPD event to sports rehabilitation practitioners and students. Taking place at UA92 in Manchester on the evening of Tuesday, 19th September 2023, the event featured presentations and practical sessions with expert guest speakers Ibrahim Kerem and Nick Grantham.

Forty sports rehabilitation practitioners, students, and staff from UA92 attended this in-person professional development and networking event.

Expert Guest Speakers

Ibrahim Kerem, (Manchester United Women)

Ibrahim Kerem is an Australian trained Sports Physiotherapist with a strong background of work in Professional Football. He has also worked as an educator at the University of Technology Sydney as a demonstrator of Human Anatomy and a lecturer of Advanced Sports Injury Management.

He spent several seasons working in the Australian A-League as Head Physiotherapist at Sydney FC, before moving to the UK to work with Blackburn Rovers FC to take up the role of Rehabilitation Physiotherapist and Clinical Specialist.

Ibrahim is the Head of Physiotherapy for Manchester United Football Club’s Women’s First team and utilises a background in Sports Science, Strength and Conditioning and Football Coaching to aid in creating athlete-centred processes and high-performance systems of working.

He has a special interest in performance rehabilitation and ACL injuries in professional football and recently presented on this topic at the Isokinetic Football Medicine conference in Lyon.

Ibrahim’s presentation, “The four key ‘FLOW’ factors to consider during non-surgical ACL rehabilitation in professional football” considered the factors affecting rehabilitation from ACL injuries in professional football.

Nick Grantham (ZERO226 Performance)

Nick’s practical, down-to-earth approach to enhanced athletic performance sees him in demand with Olympians, professional athletes, and sports teams the world over. Currently Lead First Team Strength and Conditioning coach in the Premier League, Nick has spent more than two decades working with the world’s most talented athletes, from premiership footballers to the Royal Ballet, Cirque du Soleil, and professional golfers.

Nick was one of the first strength and conditioning coaches to work for the English Institute of Sport. One of his key differentiators is his wealth of experience collaborating with allied health professionals and merging injury rehabilitation and strength and conditioning to get top athletes back to full strength and pre-injury performance levels.

“Robust, Resilient and Ready – Physical Preparation in High Performance Football”

In this presentation, Nick shared insights from his practical approach to creating strong and healthy players capable of withstanding and recovering from the demands of training and competition, ensuring they are fully prepared to perform at the weekend.

Nick discussed the application of objective measures to inform and influence his programming decisions and how he applies the concept of collective individualisation to provide tailored programmes across the first team squad.

The four key ‘FLOW’ factors to consider during non-surgical ACL rehabilitation in professional football

Ibrahim’s presentation considered:

1. An introduction to the F.L.O.W framework
2. The four factors to consider before allowing a footballer to commence non-surgical ACL rehab
3. The decision-making process around non-surgical and surgical approaches
4. Pitch and gym-based rehab process for surgically and non-surgically managed ACL injury

He discussed the medico-legal factors affecting decision-making around whether or not to commence non-surgical ACL rehab and demonstrated his ACL rehab process.

Ibrahim shared a case study from men’s football. There was emerging literature about non-surgical ACL rehab success, and Ibrahim and his previous Club were keen to consider all options available for the injured players. An informed decision needed to be taken between the MDT, player and club based on a FLOW assessment.

Ibrahim discussed the details of the injury, including the profile of the athlete, mechanism, and time of injury. The player had low to moderate confidence in the non-surgical approach pre rehab, but post rehab, their confidence was high due to a positive outcome.

The FLOW Assessment Process

Ibrahim described the FLOW process and how it was used for the case study scenario.

1. F = Future opportunities – appropriate in that league
2. L = Liability potential – shared
3. O = Organisation culture – Aggressive vs. conservative vs. balanced based on experts / based on info + needs
4. W = Wider influences and context

For the player in question, the FLOW process enabled a decision to be made that non-surgical ACL rehab is a viable option.

ACL Protocol

Ibrahim discussed the rehab phases, goals and exit criteria for both surgical and non-surgical ACL rehab. Non-surgical rehab can be completed with unrestricted return to team training in as little as 7-8 weeks, whereas post-surgical rehab can take 8-10 months.

In the case study shared by Ibrahim, after eight weeks, the player had completed all phases of rehab and passed all testing. The player could be deemed as a ‘coper’ and was ready to return to 11 v 11 football. The player had confidence post-rehab.

Ibrahim described the context of this case and the importance of applying the FLOW framework to the player’s unique circumstances before deciding on non-surgical vs. surgical ACL rehab.

Case Study 2 – Women’s Football

Ibrahim shared details of a second case study of a women’s football player who suffered a partially ruptured ACL injury, where three respected consultants provided three different opinions. The past experiences of the player and Ibrahim and external expert opinions were all used to inform the decision-making process as part of the FLOW framework.

When using the FLOW framework, it was evident that future opportunities weren’t straightforward as the player may not pass a medical with a partially ruptured ACL, and time was also a critical factor. Using the FLOW assessment framework, the decision was taken that ACL reconstructive surgery was the best option.

Two videos were shown of the player’s perspective around ACL injury, experience around the FLOW decision-making framework and key rehab take-home gems for practitioners and trainers to be aware of from an athlete’s point of view.

The player underwent a right ACL recon revision surgery using a left semi-tendinosis graft from the unaffected left leg, plus ITB tenodesis with leading surgeon Mr Andy Williams.

Ibrahim described the surgical rehab process, which takes 8-10 months and includes the following phases:

1. Knee health – regain homeostasis
2. Neuro-muscular control and load intro
3. Strength + gym exit criteria
4. Return to running (his four key phases – predictive, reactive, perturbated, clearance)
5. End stage pitch – position specific
6. Clearance + full team training

Take Home Messages

Ibrahim’s advice is rather than push our own clinical bias or club’s preference onto a player; practitioners should go with the ‘FLOW’ and consider the impact of the FLOW factors (before, during and after). Practitioners should support athletes to make informed and educated decisions.

Key Reflection

The key reflection from Ibrahim was that ACL injury does not necessarily equate to ACL surgery. Ibrahim recommends that practitioners consider ACL injury + FLOW (unique context and circumstances) to identify options.

Robust, Resilient and Ready – Physical Preparation in High-Performance Football

In this presentation, Nick shared insights from his practical approach to creating strong and healthy players capable of withstanding and recovering from the demands of training and competition, ensuring they are fully prepared to perform at the weekend.

Nick discussed the application of objective measures to inform and influence his programming decisions and how he applies the concept of collective individualisation to provide tailored programmes across the first team squad.

He reflected that practitioners should orientate the physical preparation programme around the available resources, physical attributes of the athlete and culture of the sport or team.

Athlete Attributes

He described the attributes of robust, resilient, and ready athletes:

• Robust = Strong and healthy
• Resilient = Recover easily and quickly
• Ready = Completely prepared

First Principles

Nick discussed the key principles for strength and conditioning with advice for practitioners to be brilliant at the basics. He aims to:

• Optimise athletic potential
• Work with simple solutions and symptoms (Occam’s razor)

Nick provided an example of a matrix he has developed to identify suitable modality/ exercise types for energy system development, with pros and cons for each.

He discussed the importance of rituals to create routines and rhythm for both the athlete and the multi-disciplinary team. Simple and structured training plans are in place, working around matchday. Nick also provides continuity through curriculums to ensure athletes are clear about the type of training required and how to train effectively.

He provides athletes with perceived autonomy by providing menus and electives. Athletes have a choice over the specifics of the training they do aligned to their personal goals.

Attend

Nick considered the importance for athletes to be committed and present for strength coaching sessions. A minimum effective dose of 51-70 sessions per 40-week season is required to elicit performance improvements.

Nick discussed how practitioners should know their numbers for the therapeutic range (minimum effective dose – maximum tolerated dose). He stated that the answer can’t be ‘do nothing’ and that normative behaviours are required from athletes.

Adhere

Nick described how athletes should follow and trust in the plan. Undertraining may increase injury risk, and as such, athletes should focus on the following:

• Activation – normative behaviours and consistency
• Individual (personalised) development plans
• Force production – lift – consistent exposure to a strength stimulus
• Force application – jump – horizontal jumps, vertical jumps, BOSCH jumps
• Force application – run – consistent exposure to max velocity sprints (>90%)

Nick shared details of an example plan focused on deceleration preparation and change of direction. This plan progresses athletes through the following phases:

1. Prepare for demands of training
2. Deceleration strength
3. Change of direction speed
4. Increase mobility

For strength training, Nick discussed an example plan focused on building strength to improve performance and build resilience for change of direction, acceleration, and max effort sprinting. This plan supports athletes to:

1. Overcome and control moderate loads
2. Accelerate (jumping and sprinting)
3. Vertical jumps – aerial battles
4. Foundations of reactive strength

Adapt

Nick considered critical success factors and how it’s important for practitioners to understand what adaptations drive physical performance. He provided examples of measures to assess performance improvements for hamstring, groin, hip, and calf. Regular tests are used to measure strength, power, and reactions.

Critical Success Factors – Jump Profiling

Nick discussed critical success factors and encouraged practitioners to consider the relationship between outcome and process measures, performance benchmarks, minimum detectable change, and minimum worthwhile change. In the context of jumping ability, Nick considered the relationship between jumping ability and other critical success factors.

Conclusion

To conclude a fascinating session, Nick reiterated his opening advice, “Orientate the physical preparation programme around the available resources, physical attributes of the athlete and culture of the sport or team.”

Practical sessions

The recently completed performance and sports science facilities at UA92 provided the ideal space for practical demonstrations from Ibrahim and Nick.

Jump Profiling

Nick used force plates and a plyometric box to demonstrate performance tests for jump profiling. Nick demonstrated the countermovement jump (CMJ) and drop jump (DJ).

He described how there are hundreds of variables, and it is therefore important for practitioners to identify and use a small number of primary and secondary metrics for outcome and process variables. The data available from technology is changing and growing all the time, and Nick discussed how key data such as watts per kilo should be focused on to measure performance improvement.

Nick demonstrated the technique required for the CMJ and DJ. Nick discussed the importance of intent for the athlete as they should aim to fully commit and complete performance tests with intent. Nick also considered the role of the coach in promoting good technique and using effective communication to drive consistency and maximum performance from athletes.

Nick discussed the timing and frequency of performance tests for individual players and how benchmarks are used to create a squad average. Primary metrics focus on peak power based on watts per kilo, and secondary metrics assist with the analysis of technique and performance through different phases of exercises/ tests.

ACL/ Knee Injury Special Tests

Ibrahim discussed and demonstrated the following special tests, which can be used to identify ACL injuries and the severity of injury (partial compared to full thickness), demonstrating optimal manual handling for:

1. Lachman test
2. Lelli’s (Lever sign) test
3. Pivot-shift test

He showed how to complete each test and described the technique and findings to be aware of when identifying ACL injury. Practitioners then practised the tests, and Ibrahim provided advice on the correct technique.

Follow Ibrahim Kerem and Nick Grantham

• LinkedIn – Ibrahim Kerem
• X – @coachnickg
• Instagram – @nickgrantham_coach

2023 Injury Rehab Network events

Find out about and register your interest for all the Injury Rehab Network events with BASRaT planned for 2023

About UA92

Having met at Manchester United back in the early 90s, the class of 92 (CO92) have enjoyed some of the most successful careers in football, driving their club and countries to reach new heights.

The four subject areas of UA92 connect with the group’s collective expertise, and their passion to impart this to a new generation is unwavering.

With the Class of 92 as UA92’s Co-Founders, our students benefit from their industry connections who provide unrivalled learning opportunities and career development. The principles of UA92 that underpin our curriculum reflect Gary Neville’s personal principles, which aim to prepare each and every one of our students for life.

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