REHABILITATION BELOW KNEE Around the foot and ankle tibialis anterior and posterior,

peroneals and gastrocnemius cause movement at more than one joint and so require synergic contraction of stabilising muscles to isolate a single motion. Further up the chain, active knee extension requires co-contraction of the hip extensors in order to prevent hip flexion. Without this stabilisation, the knee cannot extend with maximum strength. The type of exercises that may be reproduced can be very functional and utilise a total movement pattern.

SPORT-SPECIFIC SKILL The therapist involved in any particular sport must be prepared to look outside the realms of the medical textbook when dealing with sports-associated injuries. Knowledge of the functional factors that are required for the role of the single competitor or team player is essential. From this, specific drills that test the physical or mental approach to the task required can be created. The player must be able to demonstrate that they can perform competently, even in high-pressure situations. Different variables contribute to the intensity of the

programme. The therapist needs to adjust these at the appropriate time in order to progress the rehabilitation plan from simple to complex movements. These include the following: n Size of playing area n Number of players n Use of equipment (number of balls, cones, manikins, tackle shields and bags) n Intensity n Time n Non-/full contact n Opposed/unopposed n Physical functional components (jumping, falling, cutting) n Skill functional components (crossing, shooting, attacking, defending). There is no hiding place for the athlete in professional

sport, even when they return to competition. Many top- level sportspeople now use sports performance analysis systems that relay to the player, coach and support staff what actually happens in competition rather than what is perceived to happen. Research has shown that athletes and coaches can recall only 30% of performance correctly – so what about the other 70%? This information is also of use to the medical team individually in providing us with footage of the mechanics of the athlete in competition and gives game-related information to help make rehabilitation drills and programmes even more specific to competition.

REACTIVE NEUROMUSCULAR TRAINING Functional progression is required for a safe return to activity. Breaking down the action into a hierarchy and then performing that in sequence allows re-education and redevelopment of a specific skill. Reactive neuromuscular training (RNT) drills are designed to restore functional stability about the injured joint and those specifically distal and proximal to it, while enhancing various motor skills (17). The initial priority is to regain dynamic stability around the injured joint, as research suggests that dynamic stabilisation produced by co-contraction is inhibited due to abnormal firing patterns of the joint mechanoreceptors following trauma (18,19). Once this has been achieved, active movement

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such as walking and running can be incorporated before progressing to more complex motor and sport-specific skills. There are therefore three specific phases of progression with numerous interphase variables: 1. Static stabilisation. 2. Transitional stabilisation. 3. Dynamic stabilisation. Many adaptations are possible, depending on the demands of the athlete and the sport. Equipment required includes cliniband/tubing, harness, single-station pulley, proprioceptive aids and sport-specific equipment. There is also a logical notation system for record-keeping.

SUMMARY An organised progression of rehabilitation is the key to success in the return to sport for the injured athlete. Careful consideration of many factors, some of which we have discussed in this article, is essential in order to cover all aspects. How you adapt and utilise these factors to your specific environment is totally dependent on how three- dimensional you are.

THE PRINCIPLES OUTLINED ARE DEMONSTRATED IN A GENERAL LOWER-LIMB REHABILITATION PROGRAMME

Aims n To stimulate linked muscle units/joint proprioceptors in the lower limb. n To maintain/improve cardiovascular fitness. n To maintain/improve core stability. n To maintain sport-specific skills.

Frequency n Alternate days n Three sessions per week.

Intensity n 70–85% maximum heart rate.

Target n Lower limb joints n Lower limb musculature n Cardiovascular system.

Variables n Increase intensity n Increase degree of instability n Increase weight resistance n Increase/decrease repetitions n Adjust selected exercises n Sport-specific skills.

Numbers n Pairs.

Equipment n Balance objects n Spin bikes n Single and double pulley units n Harness n Football.

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