In this blog, I am going speak about the last stage of a rehabilitation program and what needs to be done. This is for education purposes only – please consult a clinician or physiotherapist to have your injury assessed first!

It is crucial that following a lower body injury that you complete these three categories of exercise before you go back to doing your sport.

What does late stage actually mean?

There are generally three overlapping phases of a rehabilitation program. Early stage, mid stage and late stage. Timelines and exercise selection depends on the severity of your injury, symptoms, function and sport/outcome goal. Late stage comes at the end once you have restored your range of motion, strength and back doing daily activities relatively pain-free. There is some overlap so you will still be doing some of your mid-stage exercises whilst beginning the late stage.

So let`s break the categories of late stage down further!

Category 1 – Landing, Jumping & Power

During these movements, there is going to be different joints absorbing force differently. It could useful to know that if you are recovering from a knee injury then it would be essential for you to include vertical jumps. However, if you have sustained a calf strain then including horizontal jumps would be essential.
A study completed by Kotsifaki et al in 2021 found that vertical and horizontal jumps, both load the ankle, knee and hip joints but the relative contributions from each joint will slightly differ. On a vertical jump each joint will contribute to a third of the force on take-off and landing. Whereas on a horizontal jump, the ankle and hip joints predominately drive the movement and the knee joint is the main joint to absorb the force when you land.

An example of crossover could be that you have an Achilles tendon injury and completing your strengthening based exercises which are calf raises. Then you have gone through the progressions with minimal pain and are able to achieve full sets/reps. As a rough guide, you should be able to perform 20-25 double leg calf raises without pain prior to starting the hops. This would be a green light to start the end stage exercises whilst continuing your strengthening exercises because you will have built a solid foundation of strength within the tissue, ready for the next step.

Within this category you can make any of the exercises harder or easier by altering the height of the box/step or increase or decrease your efforts. These could be small progressions made before moving onto the next exercise. The main goal is to be able to jump at maximum effort before progressing onto the next stage. Monitor your response after performing the exercises. There should be no swelling and minimal pain when completing the exercises and progressing.

Vertical jump

Level 1 – Start with a box jump since this will reduce landing impact forces

Level 2 – Perform a vertical jump, building up to a maximal effort

Level 3 – Depth Drop. Step off an elevated surface and land on two legs

Level 4 – Depth Jump. Step off, land on two legs, and then quickly jump up as high as possible

Level 5 – Single-Leg Depth Drop. Step off an elevated surface and land on one leg

Level 6 – Single-Leg Depth Jump. Land on one leg, then immediately jump up as high as you can

Horizontal jump

If you want to progress this even further then you can incorporate multiple jumps double-leg or single-leg. Once you can complete these comfortably with maximum effort, you can also complete the horizontal jumps diagonally. This will further challenge the lower limb, challenging it more than previous.

Level 1 – Double Leg sub maximum effort hop for distance.

Level 2 – Double Leg maximum effort hop for distance.

Level 3 – Single-Leg sub maximum effort hop for distance.

Level 4 – Single-Leg maximum effort hop for distance.

Level 1 – Double Leg in Place. Standing on the spot, hop up and down.

Level 2 – Double Leg Forward and Backward. Standing on the spot, hop forwards then hop backwards.

Level 3 – Double Leg Side to Side. Standing on the spot, hop to the left then hop to the right.

Level 4 – Single-Leg in Place. Standing on one leg on the spot, hop up and down on the same leg.

Level 5 -Single-Leg Forward and Backward. Standing on one leg, hop forwards then hop backwards on the same leg.

Level 6 – Single-Leg Side to Side. Standing on one leg, hop to the left then hop to the right on the same leg.

A recent systematic review in 2022 found that forward and lateral hopping placed the Achilles tendon through similar load as it would when high speed running. Therefore, it could be able to tolerate load in multi-directional.

Deceleration progression

The last lot of exercises within this category are deceleration. These exercises will emphasis single-leg landing and control. See below for exercises.

Level 1 – Forward Lunge. Perform a slow and controlled lunge with an emphasis on driving the knee forward
Level 2 – Lunge Push Back. Same as previous, but after controlling the deceleration, you will push back to the start with power
Level 3 – Forward Step & Land. Jump forward off one leg and land on the other with control. Step back and repeat
Level 4 – Step & Land with a Jump Back. Jump forward, land on the other leg, then quickly jump back to the start

Lateral deceleration progression

You can also include a lateral component to this, a side-to-side progression. See below for example of exercise progressions.

Level 1 – Lateral Lunge. Stepping out to the side then bring the other leg to it. You will eventually feel like you are walking side-ways.

Level 2 – Lateral Lunge Push Back. Stepping out to the side then pushing back off that foot.

Level 3 – Lateral Step and Land. Hopping side-ways on one leg then landing on the other.

Level 4 – Lateral Step and Land with a Jump Back. Hopping side-ways on one leg then hopping straight back on the other leg.

Quad dominant vs Hip dominant

Similar to vertical jumps, deceleration exercises, particularly the forward progression, are important for improving quadriceps function. Following a knee injury, you may unknowingly perform a hip-dominant version of the exercise to off load the knee. Throughout these movements, it is important to understand why you are doing it and what it is you are trying to achieve.

There are some rough guidelines below to get you started; however, these will need to be individualised dependent on your severity, irritability, symptoms and tolerance.

Category 2 – High speed straight line running

Following any lower body injury, being able to run at 100% maximum effort is necessary not only for returning to sport but in general life. Following on from category one and completing the deceleration phase, which is the reason why some muscle strain injuries occur, you can then begin high-speed linear running. This includes acceleration and deceleration. Now unfortunately there are no specific guidelines or this but Hickey et al in 2022 did come up with a running protocol.

 

You will not straight away sprint at 100% of maximum effort. You will instead start at moderate speeds of 50% and once this becomes manageable, you will build up to 80%. Gradually build it up and repeat this process until you reach 100% of full speed with no issues or symptoms.
It is also worth noting that the acceleration and deceleration phases are vitally important here. These are both mechanism of injury that could have injured you inthe first place. They also mimic a lot of actions within a sporting event. However, majority of this will be determined on your sport/desired outcome.

Category 3 – Change of direction
This will include actions such as pivoting, cutting and other multi-directional activities, which are all keep movement patterns that we do when we play in sport. In majority of sports there will be a variations of having to change direction at speed.

Cutting

You will want to start off with a softer angle and gradually progress it up. The less of a cut the easier it will be due to the lighter demands on the lower limb. Running straight is less demanding than running with a turn.

Cutting with speed

Y shaped

Start off at the first cone, run forwards to the second cone then cut either left or right at a 45 degree angle. Walk back and repeat. You can alter the cutting angle to make this harder (see above picture), but start with a lower intensity and increase as your tolerance allows.
You can do this pre-planned or reactive. Pre-planned is when you already know which direction you are going to go before you start. Reactive is harder because working with a partner, they will shout left or right and you will cut in that direction.

Other options include:
Zig zag runs

Set up 6-10 cones staggered with roughly 3m in-between at a rough angle of 90 degrees. You will then start and run diagonally to the opposite cone, ensuring you cut and change direction. Repeat through until you have finished the cones.

T drill

Set up your cones in the shape of a letter T. You want to start by running forward 10m, shuffle to your left 5m, then shuffle to the right 10m, before running backwards to the start to finish. Repeat this again but shuffle to the right first this time round.

5-0-5 drill

The goal here is to run forward 15m, cut 180 degrees, and run back 5m. Repeat again but perform a cut on the other leg this time round.

When can you actually return to sport again?

Like the other stages, you cannot enter the late stage phase then return to playing tomorrow. You will need to undergo the three overlapping elements of this stage to ensure you are ready to return.

For example, there are numerous tests if you are returning from an ACL injury like having a minimum of 95% quad strength compared to the other leg. Demonstrate near symmetry in a single-leg drop jump and single-leg jump. Will all need to be ticked off before proceeding back into sport.

You will first of all return to practise or training. Slowly and progressively return back to modified sessions alongside your rehab program. Then you will return to your sport by fully participating in your sport but not quite at your desired level e.g. playing half of the game. Before lastly returning fully to competition and performance. Whereby you are able to return without restriction and perform at your highest standard.

Again, unfortunately there is no exact criteria that you need to meet in order to be given the go ahead to return to sport but there is a rough guide which follows:
1. Clinically. Do you have pain, swelling, and instability?
2. Functionally. What is your range of movement, strength and power like?
3. Biomechanically. Can you demonstrate good quality movement without compensation?
4. Psychologically. Do you feel ready to return?
5. Sport specific. Have you built up to the appropriate volume and intensity of your sport?

If all of these guidelines have been achieved and you feel ready to go, return to play is done!

Thank you for reading this. Please contact us with any questions that you may have or give us your feedback with your thoughts.