Introduction
Traditionally, rehabilitation and the return to play (RTP) process have been viewed purely through a biomechanical and motor system lens. This viewpoint ignores the performer-environment relationship, athletes as complex adaptive systems, and the importance of athletes being embedded in alive movement problems of varying complexity (Yearby et al., 2022) during the RTP process. In short, it has created a “gap” between what an athlete experiences in traditional rehab settings and what they will face during competition. If you’re interested in learning more about the “gap,” then please read Part 1 of this blog series (Insert previous blog link). As was stated in Part 1 (https://emergentmvmt.com/bridging-the-gap-between-return-to-play-and-performance/), it’s time to view injury and rehabilitation as an ecological event that can affect how an athlete perceives and interacts with their environment.
Affordances
Affordances are opportunities for action that are both athlete and frame-dependent (Gibson, 1979). The Greek philosopher Heraclitus stated, “No man ever steps in the same river twice, for it’s not the same river and he’s not the same man.” This notion implies that no two experiences are the same, which means the perception of affordances is highly context-dependent and influenced by the interacting constraints on behavior. Moreover, whether the athlete chooses to act on an affordance is highly individualized. Affordance perception can be influenced by many factors, including but not limited to height, age, experience, intentions, and previous injury history. These individual factors tend to be more obvious and more understood. But other factors such as game situation, tactics, position, field conditions, and intentions can differ from moment to moment and also play an important role in affordance perception.
The field of affordances includes soliciting affordances understood as action possibilities in a particular situation from a particular person (Coninx & Stilwell, 2021). With that in mind, consider how an injury might affect an athlete and their grip on the field of affordances (Bruineberg and Rietveld, 2014). If a rugby player has previously suffered a dislocated shoulder and is experiencing his first live game action since the injury, how likely is he to use that shoulder to attempt a tackle? How might that affect his intentions as he interacts with the game?
As practitioners, one of our main goals is to help facilitate an athlete in their search for functional movement solutions to a wide range of problems that they may face in their sport. Another way to look at this is what Shawn Myszka talks about in helping athletes “expand their movement toolbox” so that they are capable of potentially harnessing the solutions as they connect to the information in each problem they face. Unfortunately, injury can limit how an athlete perceives the world and its affordances, which impacts the problem-solution relationship. The way an athlete was capable of solving problems in the past might not be what they’re capable of now. It is our job as practitioners to create learning environments where our athletes can problem-solve, and adapt in a functional way. With the rugby example mentioned above, could an activity be designed to allow the athlete to experience some contact with his shoulder in a way similar to (although with much less intensity) what he might use in a match? Additionally, general movement activities that could include some crawling, tumbling, or grappling may give the athlete the confidence they need to eventually utilize the shoulder effectively again in competition. Although these general activities may not look exactly like rugby, the athlete is allowed to move with autonomy and experience variability of movement in a way that could be relevant to the sport. I would also argue that activities like these are going to be much more valuable to that athlete than having them go through the same, static shoulder care routine for the 500th time. As the athlete gets further and further in the RTP process, the activities should continue to look, feel, and act more like their respective sport.
Anxiety, Pressure and Stress
It has been shown that anxiety causes subjects to underestimate their action capabilities, which suggests anxiety affects the perception of affordances (Graydon et al., 2012). Anxiety and stress must be prioritized when considering what an athlete might experience when returning to sport.
It is often the tendency, in traditional rehab settings, to shield or insulate an athlete from anxiety, stress, and variability. However, when we consider that these components will be present in competitive environments, this approach could be misguided. Rather than having an athlete undergo the entire RTP in a controlled, predictable environment, wouldn’t it be better to have them experience “slices” of the game (Yearby et al., 2022) prior to fully returning to their sport?
To illustrate the complex role that anxiety plays in behavior, I’d like to share a story about a high school American football player I worked with who was returning from an ACL injury.
The athlete referenced in this story was a high school American football player who tore his ACL in early September 2020. He played the position of tight end and is currently playing Division 1 football. He tore his ACL near the end of a team practice while running routes. He started working directly with us around 5 months post-op. Prior to that point, he had been working exclusively with his physical therapist. As our work together progressed we began to allow him to experience more relevant and more complex movement problems. On this particular day (around 10 months in) we were headed outside for our first “field session”, where he would be engaging in the most representative learning environment that he had experienced up to this point. Our intentions for this session were for him to face movement problems with a higher degree of complexity while engaging with a variety of opponents. This included him running full-speed routes against various defenders, and playing various coverages. Prior to that, our sessions had been in our facility, and his most frequent opposition was me. As an opponent, given my physical stature and athletic abilities, I offer a less representative opponent than the ones he would be facing. His opponents on this day were all active senior-aged high school American football players or college-level American football players.
As the session was beginning and he was going through his movement prep, he turned and nervously said to me, “I haven’t worn these cleats since I tore my ACL”. Immediately, a knot began to form in my stomach, and I became nervous. If I, as his movement skill acquisition coach on the sideline was nervous, imagine the anxiety he was experiencing at that moment. It should be noted that this was a controlled session, with only minimal incidental contact, no spectators present, and no score is kept. Obviously, this environment was not nearly as chaotic and stressful as the experience of playing the game. As he progressed in his training, more and more relevant information was added to these sessions. Constraints such as varying field conditions, number of defenders, and equipment (helmet, pads) were included in the sessions. At any level of skill, stress, and anxiety are likely to play a factor in return from injury. I believe it is much better for our athletes to experience stress and anxiety gradually throughout the RTP process rather than to be thrown into the fire and risk them being overwhelmed and potentially reinjuring themselves.
Guiding Attention and Intentions
In traditional ACL rehab settings, exercises are often completed with an internal focus of control, with full attention directed toward the internal aspects of the movement (i.e., avoiding knee valgus, and excessive knee flexion) (Grooms et al., 2015). With an increased focus on the body, rather than the information present in the environment, the athlete may be unable to perceive and become attuned to, the most relevant affordances which may be available to them in their sport. In my time as a sport movement coach, I’ve seen many post-knee injury athletes enter our facility and perform their initial movement prep with their gaze fixed on the ground, unaware and unable to perceive what is happening around them. In my observation, this is often due to an overemphasis and hyperfocus on their biomechanics during their rehab process. Taking this overly internalized approach could potentially lead to fixed and frozen movement behavior, where an athlete is “hyper-focused” on the details of their own movements rather than on their environment. This can not only reduce performance output but potentially increase the risk of (re)injury, as well. Imagine a basketball player who has experienced a left knee injury and is playing with the constant thought that landing with her knee in a valgus position could potentially cause re-injury. How likely is it that she will perform at her best in this type of state? Is it possible that she then avoids landing on her left knee and begins to compensate on her right side, potentially leading to a new (but related) injury?
One possible solution is to direct an athlete’s focus of attention toward their environment. This can be achieved by guiding the athlete’s attention and intentions during their session (Jacobs & Michaels, 2007). Thus, rather than having the athlete focus on their own biomechanics, we could guide their attention towards focusing on the emerging movement problem in front of them. We could set up environments that allow for the athlete to explore various potential movement solutions rather than prescribing one “ideal” way of moving and behaving.
Taking the previous example above, an activity could be designed that allows the athlete to experience landing forces in a way that directs their attention to solving the problem, rather than on her knee. Rather than having the athlete repeat the same “perfect” landing in training, you could design an activity where the athlete has to catch or “high point” a ball and then land safely, similar to what might be required of them when playing basketball (i.e., rebounding, shooting, blocking, etc). You could even add in some contact to perturb their landing or have the athlete attempt to land in a specific zone or area. This could guide the athlete’s attention and intention towards the problem rather than solely focusing on their own biomechanics. In research by Grooms et al., it has been shown that athletes who’ve experienced an ACL injury often become over-reliant on their visual system (2015). A perturbation may also encourage them to self-organize using other key sources of perceptual information.
Conclusion
As mentioned previously, the prevailing view of the RTP process has been mostly limited to emphasizing the importance of biomechanics and motor systems. While qualities such as joint kinematics and strength are important, I believe that when you truly investigate sport movement and all its complexity, this view of the RTP process comes up short. I believe, as a field, we must begin to look at the RTP process through a different lens; a lens that views sport movement behavior as a complex interaction between an athlete and their environment; one that views the athlete as a complex, adaptive system rather than something that can just be “fixed” by merely improving one of its component parts. If we are able to do this, we may be able to get closer to successfully reintegrating our athletes back into the sport they love.
Javier Miler-Estrada
References
- Bruineberg, J., & Rietveld, E. (2014). Self-organization, free energy minimization, and optimal grip on a field of affordances. Frontiers in Human Neuroscience, 8.
- Coninx, S., & Stilwell, P. (2021). Pain and the field of affordances: an enactive approach to acute and chronic pain. Synthese, 199(3–4), 7835–7863. https://doi.org/10.1007/s11229-021-03142-3
- Gibson, J. J. (1979). The ecological approach to visual perception. Houghton Mifflin.
- Graydon, M. M., Linkenauger, S. A., Teachman, B. A., & Proffitt, D. R. (2012). Scared stiff: The influence of anxiety on the perception of action capabilities. Cognition & Emotion, 26(7), 1301–1315. https://doi.org/10.1080/02699931.2012.667391
- Grooms, D., Appelbaum, G., & Onate, J. (2015). Neuroplasticity Following Anterior Cruciate Ligament Injury: A Framework for Visual-Motor Training Approaches in Rehabilitation. Journal of Orthopaedic & Sports Physical Therapy, 45(5), 381–393. https://doi.org/10.2519/jospt.2015.5549
- Jacobs, D. M., & Michaels, C. F. (2007, September 21). Direct Learning. Ecological Psychology, 19(4), 321–349. https://doi.org/10.1080/10407410701432337
- Yearby, T., Myszka, S., Roberts, W. M., Woods, C. T., & Davids, K. (2022). Applying an ecological approach to practice design in American football: some case examples on best practice. Sports Coaching Review, DOI: https://doi.org/10.1080/21640629.2022.2057698
Javi is the co-founder of Ignite Performance in Chandler, AZ. Ignite is one of the premier training facilities in the region. Ignite works with athletes from the youth to professional levels, and specializes in developing High School athletes. As a team, they have helped over 100 athletes obtain college scholarships.
