Real Madrid Injury Report: The rehab seems to be going well

Even more encouraging were the pictures released by Sergio Ramos of some of the work he's currently doing with his injured shoulder.  The one of him exercising holding the free-weight while side-stepping is quite a difficult movement to perform for anyone who's fully fit never mind recovering from an AC joint sprain.

The idea of this exercise is to work the muscle as part of the overall shoulder complex as opposed to singularly loading the affected area.  The shoulder works as a complex unit and needs to be rehabbed as such.  If he's able to exercise in this way, then it's so much more effective than just carrying out endless sets of reps on an isokinetic exercise machine.  The shoulder joint is designed to be functional, and although Sergio's injury is to the acromio-clavicular joint of the shoulder, the ACJ needs to be rehabilitated as part of the overall shoulder complex and ideally in a functional manner.

Functional exercises form the basis for post-injury rehab programmes and if further or recurrent injury is to be avoided, the shoulder needs to be strong enough to resist the forces that can damage the muscles, ligaments and tendons of the joint.  Elastic theraband exercises are popular and important when targeting the smaller, deeper muscles that stabilise the shoulder but it's essential that any exercises simulate the real-life day-to-day stresses that the shoulder has to contend with.  It's a common discussion topic among physiotherapists, fitness coaches and the like, that rehabilitation after shoulder injury is often thought to consist only of theraband work and using isokinetic machines in the club gym.  The reality is far from the truth.

If a shoulder or any other joint is going to recover from musculo-ligamentous injury then the exercises not only need to be performed at a level where they will be beneficial, the exercises themselves need to be functionally-based.  Sergio Ramos is pictured using a large flat weight which he's holding in both hands and performing side-steps while keeping the flat weight slightly away from his body as he moves from side to side.  Just keeping the weight in the one position is an exercise in itself, but by adding the sidewards movement the functionality of the shoulder increases as the muscles all have to act in unison to hold the upper limbs in position.

The progression on this exercise would be to slightly alter the angle that Sergio is holding the weight at in order to transfer more of the load on to the injured side as the shoulder gets stronger; and continue until he's able to perform the same exercise using an appropriate weight that can be held using only the one arm.  The next stage would then to be perform the exercises while moving the weight to increase the strength of the shoulder in different positions and through various ranges of movement ending with overhead movements.

Exercising injured joints in this way is so much more effective than isolating specific movements.  In real life, often the specific movements practised during gym-based exercise are unrealistic and are only ever performed in a gym setting as opposed to on a football field or in any role that demands strength and flexibility such as that of a firefighter for example.  Numerous websites demonstrate exercise routines based around holding a theraband or rubber tubing and doing three sets of ten arm-raises for example, but if exercises are going to be worth performing then they need to simulate the realistic movement patterns.  If this is the level that Sergio Ramos is currently working at then he's certainly making good progress compared to this time last week.

It's also good to see him running and bounding etc.  This can still affect the shoulder if it's painful but at the moment the two main obstacles to Sergio Ramos' return to the team will be the risk of incomplete healing of the injured ligaments and a lack of strength to provide proper support.

Gareth Bale has apparently been doing a lot of strengthening work too, for his injured calf.  This sounds as though it could be a difficult injury to get over based on the fact that he's suffered with calf muscle strains for a while now.  The calf muscles are always active in daily life since they're affected by every step and are difficult muscles to strengthen.  In fact, the calf group can be one of the hardest muscles to rehabilitate based on the fact that they are so active in daily life.

Gareth Bale will have been on an intensive programme and a lot of this will have been gym-based; but with apologies for stating the obvious, the key factor is always whether the muscles are going to be strong enough afterwards to withstand the explosive forces generated in football that they are going to be subjected to on his return.

Although the last ten days or so will have been spent mainly on gym work, the need to progress to outside running and changing direction, ball work etc will have to be counter-balanced by the fact that Gareth has already suffered a few injuries of this type.  Any setbacks in this respect will be a real knock to his confidence.  Sometimes it's better just to accept that you're going to be out for a while and make trebly sure that the risk of recurrence is kept to an absolute minimum.