Dr. Mary Kate Casey’s On Field Progression of the Controlled → Uncontrolled Chaos Continuum
On Field Progression – Why do we document everything else in our rehab but the most important stuff. We record reps, sets, and time for our athletes when they are running, jumping or completing strength exercises, but we have failed our patients by not properly PRESCRIBING return to sport controlled to uncontrolled play.
We are trusting our “gut” on frequency, intensity and duration and therefore are missing a proper evidence based progression when it comes to the on field sport specific activities and game play. We are allowing athletes to compete in drills based on their psychological readiness and often forget to properly DOSE return to play as an exercise prescription. This is often missed because more often than not because unless an athlete is rehabbing in college or as a pro, patients are not monitored by a PT, ATC or strength coach during their practices. As rehab professionals, we are failing our patients by not giving our patients clear guidelines and specific drills and activities they can participate in during practice. All too often we are keeping our athletes out until the 9 month mark, and then let them go from 0-100 without introducing them to contact and game-like play in a controlled setting.
We treat this phase of rehab as a question mark. We ask our players… Do you think you can go 100%? Do you feel ready to play with a defender making contact? Do you need to come out? Or Do you think you can play for 30 min?.
After doing A LOT of research and realizing there is a lack of research in the Return to Sport Strength and Conditioning and Return to Contact Play area, I began creating my own advanced Return to Sport and Return to Contact protocols. As an elite lacrosse player, the Return to Run programs out there didn’t have the appropriate intensity and there nothing out there regarding contact play but one article by Matt Tabenar in the UK, I have modified his Controlled Chaos Continuum and made it my own. I have developed a more clinical, specific, reproducible, and actionable model in which medical professionals can communicate to each other via the athlete and evidence based programming. I am starting to call this Phase 6 of ACL rehab, as it currently is the “why not, let’s give it a try phase”. With little evidence or knowledge to support the decision making, the fatigue factor that often lands our athletes on the sidelines not too soon after returning to sport with compensation injuries or the ever so dreadful re-injury.
It’s not if an athlete is going to get reinjured, it’s when. This sounds very pessimistic, however its the truth. The stats are stacked against us and we as medical professionals need to do more about it. We need to start solving the problems we see everyday in our offices and we need to start making a change.
If we can take a more controlled and evidence based approach to On field Progressions, our athletes will be safer in returning to sport and will have had the exposure and reps they need to feel confident, prepared and conditioned to participate in a full contact game without time restrictions.
On Field Progression of the Controlled → Uncontrolled Chaos Continuum
Return to Participation
- Progressing reps, sets, and enforcing time limits
- Non-contact Drills→ Controlled Non-Contact Play → Controlled Contact Drills→ Controlled Contact Play → Uncontrolled Contact Drills (progressing reps, sets, time limits)→ Uncontrolled Contact Play
- Non-Contact Drill- Lacrosse Shooting on goal 50% of speed, focus on change in direction landing and loading, 20 reps, 2-3 times per practice
- 3 man weave
Return to Sport
- Progressing reps, sets, and enforcing time limits
- Controlled Contact Drills- 1v1 – Attacker goes 100% but defender goes 50% limiting contact and aware of injury- 10 min
- Controlled Contact Play- 7v7 – Attacker goes 100% but defender goes 50% limiting contact and aware of injury- 10 min
Return to Performance
- Progressing reps, sets, and enforcing time limits
- Uncontrolled Contact Drills- Lacrosse 1v1 attacking player goes 100%, no limits on defender, 10 reps
- Uncontrolled Contact Play but Controlled Fatigue Factor
- Uncontrolled Contact Play- 100% attacker and defender in game play ½ field, subbing in and out every 5 mins for a total of 30 min per game
- Uncontrolled Contact Play- 100% attacker and defender in game play ½ field, subbing in and out every 10 mins for a total of 40 min per game
- Uncontrolled Contact Play- 100% attacker and defender in game play full field, subbing in and out every 10 mins for a total of 40 min game
- Uncontrolled Contact Play- 100% attacker and defender in game play full field, subbing in and out every 20 mins for a total of 50 min game
- No time Restrictions
- Uncontrolled Contact Play- 100% attacker and defender in game play full field
- Player Initiated (controlled) and Play reactive
- Preplanning vs reactive
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It’s important to note that the athletes first full game should NOT be the first time they are cleared to play. We need to do a better job of communicating with players, parents and coaches on the dosage of return to full play restrictions and how that will in turn not only provide safety for the athlete but improved performance and safety in the game. Following this protocol, we aim to reduce the risk of re-injury, muscle strains and compensation injuries, all while giving the athlete more time to gain exposure in real game-like situations without pushing vulnerable and fatigued muscles over the limit.
In addition to following on Field Progression of the Controlled → Uncontrolled Chaos Continuum, it is imperative that these recovering athletes prioritize active recovery days and listen to their bodies when progressing into full Return to Performance protocol.
Resources:
Taberner M, Allen T, Cohen DD Progressing rehabilitation after injury: consider the ‘control-chaos continuum’British Journal of Sports Medicine 2019;53:1132-1136.
https://ijspt.scholasticahq.com/article/25463-acl-return-to-sport-testing-it-s-time-to-step-up-our-game
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