[ clinical commentary ]

MATTHEW BUCKTHORPE, PhD1 • FRANCESCO DELLA VILLA, MD1 • STEFANO DELLA VILLA, MD1 • GIULIO SERGIO ROI, MD1

On-field Rehabilitation Part 1:

4 Pillars of High-Quality On-field
Rehabilitation Are Restoring Movement
Quality, Physical Conditioning, Restoring
Sport-Specific Skills, and Progressively
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Developing Chronic Training Load

F
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

ewer people return to sport3 and more people sustain reinjury42 Completing on-field rehabilitation is
after long-term injuries such as anterior cruciate ligament (ACL) associated with superior muscle strength
rupture than clinicians and patients would desire. Returning and knee function, better patient-report-
ed outcomes, superior cardiovascular
to sport after injury is a complex multifactorial process and
fitness, and lower risk of reinjury upon
requires a biopsychosocial approach.2 One aspect of the return-to- RTS.16,17 Given the importance of on-field
sport (RTS) plan after ACL reconstruction that has received limited rehabilitation,16,17,29 it is essential that
attention is on-field rehabilitation. practitioners who work with athletes af-
On-field rehabilitation represents the for the demands of his or her sport.10 As a ter long-term injuries plan and deliver a
Journal of Orthopaedic & Sports Physical Therapy®

period when the athlete is transition-
ing from gym-based rehabilitation to
the competitive team environment.10 A
progressively stronger focus on return
to performance during the RTS process
is required to better prepare the athlete
UUSYNOPSIS: Outcomes following long-term
injuries such as anterior cruciate ligament rupture
are unsatisfactory. To improve outcomes, we must
improve rehabilitation practices. One aspect of the
return-to-sport process that has received limited
attention is on-field rehabilitation. This article
is part 1 of a 2-part series aimed at discussing
the important elements of on-field rehabilitation
and illustrating how they can be applied across a
5-stage on-field rehabilitation program following
anterior cruciate ligament reconstruction. The
intention of on-field rehabilitation is to support
athletes in their transition back to sport after
injury, from standard rehabilitation to return to the
consequence, RTS plans must emphasize
performance-based training throughout
recovery: a continuum of on-field reha-
bilitation, safe return to team training,
safe return to competitive match play,
and safe return to performance (FIGURE 1).
team or practice. In part 1, we describe 4 pillars
of high-quality on-field rehabilitation: (1) restoring
movement quality, (2) physical conditioning, (3)
restoring sport-specific skills, and (4) progressive-
ly developing chronic training load. In part 2, we
describe how these pillars may be combined into
a 5-stage on-field rehabilitation program to help
athletes transition to team practice and match play
following anterior cruciate ligament reconstruction.
J Orthop Sports Phys Ther 2019;49(8):565-569.
doi:10.2519/jospt.2019.8954
UUKEY WORDS: anterior cruciate ligament, on-
field rehabilitation, reconditioning, rehabilitation,
reinjury, return to sport
well-designed on-field rehabilitation pro-
gram. Hence, there is a need to translate
research into practice and to provide an
evidence-informed framework that can
be directly implemented into practice.
The aim of this 2-part series is to dis-
cuss the important elements (4 pillars)
of on-field rehabilitation (part 1) and
to illustrate how these can be applied
across a 5-stage on-field rehabilitation
program (part 2) to support the athlete
in his or her transition back to sport
after injury. We frame these principles
and practices around an example of re-
turning to soccer after ACL reconstruc-
tion. We expect that these principles and
practices apply to all severe (greater than
28 days of time loss)21 sports injuries
from which the athlete intends to return
to competitive sport.

1
Isokinetic Medical Group, Education and Research Department, FIFA Medical Centre of Excellence, Bologna, Italy. The authors certify that they have no affiliations with or
financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr
Matthew Buckthorpe, Isokinetic Medical Group, 11 Harley Street, London W1G 9PF UK. E-mail: M.Buckthorpe@isokinetic.com t Copyright ©2019 Journal of Orthopaedic &
Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 | 565
 [ clinical commentary
Four Pillars of High-Quality
On-field Rehabilitation
The key elements of high-quality on-field
rehabilitation are directed toward helping
the soccer player safely return to training,
competition, and performance. High-
quality on-field rehabilitation is achieved
with a dual focus on rehabilitation factors
and sport-specific performance require-
ments. Thus, a full understanding of late-
phase rehabilitation principles on one
side (such as neuromuscular control and
movement quality) and of training and
match demands on the other is essential
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to ensure that an athlete is effectively pre-
pared to RTS and that specific risk factors
for a second ACL injury are addressed. In
this complex process, we identify 4 pil-
lars underpinning high-quality on-field
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
rehabilitation: (1) restoring movement
quality, (2) physical conditioning, (3) re-
storing sport-specific skills, and (4) pro-
gressively developing chronic training
load (FIGURE 2). These 4 pillars represent
the sum of scientific knowledge and, to-
gether, characterize the final part of on-
field rehabilitation.
Restoring Movement Quality Residual
Journal of Orthopaedic & Sports Physical Therapy®
movement impairments following ACL
reconstruction are apparent during an
array of functional movements.14,15,30,39 An
ACL injury results in altered movement
bilaterally when compared to preinjury
movement quality,23 suggesting the need
Rehabilitation Performance
Rehabilitation phases OFR RTT RTC RTP
FIGURE 1. A return-to-sport 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; RTT, return to training. Modified with
permission from Buckthorpe et al.10
566 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy
for movement retraining for all patients
with ACL reconstruction. Neuromuscu-
lar training does not directly improve
movement quality during sport-specific
movements. There is a need to incorpo-
rate sport-specific movement practice to
relearn and improve movement coordi-
nation during sport-specific movements.8
It is essential to train motor control in a
progressive manner, with small incre-
ments in movement complexity.43
Progressive retraining of sport-
specific movements should begin with
a general coordination program that
gradually increases the complexity of
preplanned movements (eg, a progres-
sion from simple curved running drills
to high-speed change-of-direction tasks)
to facilitate motor learning and increase
the athlete’s movement confidence.
Then, reactive and agility movement
training can commence (ie, open tasks
in which the movement must react to an
external stimulus), followed by retrain-
On-field
Rehabilitation
FIGURE 2. The 4 pillars of OFR: (1) restoring movement quality, (2) physical conditioning, (3) restoring sport-
specific skills, and (4) progressively developing chronic training load.
]
ing sport-specific movements: perform-
ing reactive and agility movements in
which there are soccer-specific elements,
with and without pressure from an op-
posing player.
There are many contextual differenc-
es between the controlled preplanned
movement tasks indicative of the gym,
the on-field “coordination program” in
the early stages of on-field rehabilitation,
and soccer-specific movements. These
include the reactive nature of the move-
ments, as well as the environmental stim-
uli and decision-making requirements of
the tasks. Thus, it is important to include
realistic environments to practice and re-
learn motor control, ensuring a sufficient
amount of practice to maximize motor
learning. This must be planned according
to the individual needs of every injured
player to enhance performance and pre-
vent reinjury.
Altered movement quality after ACL
reconstruction has been prospectively
Movement quality
Physical conditioning
Sport-specific skills
Training load
 linked with elevated secondary ACL
injury risk.27,32,33 Limiting movements
that increase external knee moments,
which may be related to secondary ACL
risk (eg, ipsilateral trunk leans,24 ab-
normal hip kinematics,37 and knee val-
gus angles18,25,37), and increasing knee
flexion are biomechanical milestones
of ACL injury prevention. Identifying
and resolving these movement impair-
ments are also important for secondary
ACL injury prevention. This should in-
volve a progressive approach of training
and testing to achieve good movement
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quality (no presence of altered frontal
or sagittal plane alignment) during bi-
lateral (such as jumps) and unilateral
movements26 (decelerations and cutting
tasks), followed by sport-specific move-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ments on the field.
Physical Conditioning A key part of on-
field rehabilitation is to prepare players
for the specific physical demands of soc-
cer. One area that typically receives insuf-
ficient attention after ACL reconstruction
is soccer-specific physical conditioning
and ascertaining whether the player has
sufficiently restored his or her soccer-
Journal of Orthopaedic & Sports Physical Therapy®
specific fitness profile.
During a typical soccer match, top-
level outfield male players cover up to 13
km, at an average intensity close to the
anaerobic threshold (ie, 80%-90% of
maximal heart rate).4,40 The intermittent
nature of play means that players repeat
high-intensity bouts of activity every 4 to
6 seconds,40 which must be supported by
a high rate of energy, mainly from anaer-
obic glycolytic sources. During recovery
periods between bouts of intense activity,
aerobic metabolism predominates. Aer-
obic metabolism also covers the energy
requirements during submaximal-in-
tensity play. Therefore, aerobic and an-
aerobic characteristics are important for
soccer players. Although a good level of
cardiovascular fitness can allow for per-
formance of relevant movement tasks, an
extreme level of aerobic fitness does not
appear to be necessary for a high level of
play.40 Soccer players do not fully restore
their aerobic fitness 6 months following
journal of orthopaedic & sports physical therapy | volume 49 | number 8 | august 2019 |
ACL reconstruction,1 highlighting the
need to incorporate a greater focus on
cardiovascular reconditioning.
As well as aerobic fitness, soccer players
challenge the anaerobic glycolytic system.
Blood lactate concentrations recorded
during soccer matches range from 2 to12
mmol/L, with recorded individual values
in excess of 12 mmol/L,28 suggesting the
need to restore anaerobic fitness and ex-
pose players to fatiguing scenarios during
on-field rehabilitation. Fatigue from short
periods of high-intensity anaerobic work-
loads manifests in reduced neuromuscular
and athletic performance.11,19,35 In addi-
tion, although the research is equivocal,5,6
experimentally induced fatigue has been
shown to result in altered movement qual-
ity,24,31 and may contribute to biomechan-
ics9,12 during sport-specific movements
that increase the risk for ACL injury. Fur-
thermore, the combination of fatigue and
unanticipated movement (typical of team
sports) appears to create the greatest risk
for ACL injury.12
The anaerobic pattern of speed and
agility may distinguish between stan-
dards of play in soccer and should be a
key priority of RTS and performance
training.20,34,40 Therefore, it is important
to include sufficient volumes and intensi-
ties of anaerobic training during on-field
rehabilitation.
Specific training is required to target
aerobic and anaerobic (ie, speed, power,
and agility) fitness, as these are impor-
tant aspects of on-field reconditioning.
Cardiovascular conditioning should be an
important element of rehabilitation after
ACL reconstruction, using modalities
such as a bike, cross-trainer, and swim-
ming pool. Ensuring specific stimulus to
challenge the cardiovascular system on
the field and monitoring this work with
heart-rate technology are recommended.
The clinician may incorporate additional
testing in these areas to understand the
athlete’s current physical fitness: aerobic
and anaerobic threshold tests for car-
diovascular fitness (eg, running speed at
lactate threshold, yo-yo intermittent re-
covery), speed (eg, 30-m sprint running),
and change-of-direction ability (eg, 5-0-5
change of direction test, the T test or pro-
agility test). The clinician may also assess
progress and readiness to RTS.
Restoring Sport-Specific Skills Soccer
players need technical and tactical skills
to compete in training and matches. Af-
ter an ACL injury, the player will have
spent substantial time away from soc-
cer, which can negatively affect perfor-
mance from technical and tactical points
of view. Similar to movement in general,
soccer tasks need to be practiced prior
to RTS to attain optimal coordination/
performance during these tasks. The
technical and tactical components of
soccer form 3 distinct groups: (1) indi-
vidual technical skills, (2) small-group
play, and (3) full-squad play. Individual
technical skills can be further separated
into technique and skills. Technique is
the performance of a task, such as pass-
ing or shooting, without pressure from
other players. Skills are the performance
of these techniques in the sporting con-
text, that is, under pressure from an
opponent at realistic speeds. It is im-
portant to allow the player to practice
all techniques and skills prior to RTS,
for confidence and performance and to
ensure safe movement patterns during
the specific actions. Anterior cruciate
ligament injuries typically result from
the involvement of opposing players, ei-
ther after being pressed or when regain-
ing balance after a technical gesture.41
In on-field rehabilitation, confirming
movement safety during all soccer-spe-
cific movements and skills is important
to prevent reinjury.
On-field rehabilitation is the ideal en-
vironment to support restoration of indi-
vidual technical skills and tactical play,
while team-based elements (eg, phases of
play, small-sided matches, full-size prac-
tice, and competitive matches) can only be
targeted as part of return to team train-
ing and/or match play. There should be a
gradual transition from individual train-
ing to small-group and then team-based
training. On-field rehabilitation is there-
fore psychologically challenging, and even
567
 [ clinical commentary
during relatively simple tasks, the soccer
player’s performance will be initially much
lower than he or she is used to.
On-field rehabilitation should expose
players to a continuum of increasingly
difficult and complex tasks, supporting
their technical restoration and confi-
dence development.43 In addition, there
is a need to gradually reduce task con-
straints, increase the number of options/
decisions, and reflect the scenarios of
soccer-specific training in a progressive
manner. It is essential to have a thor-
ough understanding of the technical and
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skill demands of soccer and to gradually
transition a player from very simple to
highly complex soccer-specific scenarios
in a safe manner. Having either a well-
trained, soccer-specific on-field reha-
Copyright © 2019 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
bilitation specialist or involving a soccer
coach in the on-field rehabilitation pro-
cess is recommended.
Progressively Developing Chronic Train-
ing Load An often-neglected component
of end-stage rehabilitation is ascertain-
ing whether a player has played enough
to cope with the demands of training
and match play.7 Load progression is a
Journal of Orthopaedic & Sports Physical Therapy®
key part of every rehabilitation protocol
and RTS decision making. Inappropri-
ate loading may affect performance and
increase injury risk.22,38 Spikes in train-
ing load (acute load) relative to what an
athlete has been used to (chronic load)
may increase injury risk.7,38 Various com-
binations of an athlete’s chronic training
load (eg, average training load over the
last 28 days during on-field activity) and
the expected acute training (eg, 7 days of
average loading in the first week upon
return to team training) could influence
injury risk.22 Prolonging rehabilitation
and RTS might reduce the risk of subse-
quent injury by nearly 5-fold.7 Therefore,
progressively developing and obtaining
sufficient chronic load are essential ele-
ments of on-field rehabilitation.
Load management in RTS is challeng-
ing because of limited evidence to guide
the clinician. Clinicians must balance the
evidence and theory with clinical experi-
ence to best plan workload progressions
568 | august 2019 | volume 49 | number 8 | journal of orthopaedic & sports physical therapy
and RTS decision making.36 Quantifying
and managing load are key elements of
RTS, and global positioning systems can
provide a valid measure of external loads
to quantify/objectify this process.13 It is
essential that load be considered in the
context of the other pillars we described
in this paper, ensuring that every “work-
load” is achieved under the soccer-spe-
cific context in line with the functional
recovery status of the individual player.
Thus, the fourth crucial characteristic
of on-field rehabilitation is combining
objective data with context-specific ele-
ments to ensure the correct stimulus for
adaptation and the correct environment
to support RTS.
Summary
On-field rehabilitation is a complex
process based on restoring movement
quality, physical conditioning, restoring
sport-specific skills, and progressively
developing chronic training load. These
constitute the 4 pillars of high-quality
on-field rehabilitation, allowing the clini-
cian to effectively bridge the gap between
gym-based rehabilitation and the com-
petitive team environment. Understand-
ing the demands of the sport and the risk
of reinjury will help the rehabilitation
clinician devise a program to effectively
prepare the athlete to safely return to the
team and be prepared for competition
and performance. t
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