Sports Injury Rehabilitation
Photo Credit: John Arano
Objectives of Sport Rehabilitation - The Fundamentals
As an overview, effective rehabilitation should always be a staged process aimed at promoting recovery, expediting return to sport, optimising performance, and preventing re-injury.
Naturally, an athlete will always want to return to peak activity, perhaps more so at professional (paid) and elite competition levels as opposed to the amateur (unpaid) level.
Time spent on the sidelines through injury and, or lacklustre performance at the professional level within a sport, can make or break a career.
So the incentive to compress the recovery timescales, to make the most rapid return to sport after injury always carries a level of risk which must be weighed up carefully.
At the elite sports level, the presence of training professionals and coaches augments optimum support conditions for a return to top performance levels.
In situations with less access to such a positive supportive environment, the return to top performance levels after an injury may statistically be over a more sustained period, but in both environments, there are short and long terms risks to be considered.
Is the rehabilitation objective to return to a pre-injury performance level?
From a sports medicine practitioner's perspective, and notwithstanding that the injury could have been caused through a collision or impact, the rehabilitation process seeks to attain a higher level of performance and capability than previously enjoyed.
Recovery time depends on the severity of the injury, some taking days or weeks or longer, but a thoroughly planned rehabilitation is critical.
Logically, if we return the athlete to their former performance status, then it follows that they will be more susceptible or vulnerable to a repetition of the same injury type than before from a physical and psychological perspective.
Our objective, therefore, is to allow them to return to the competition level, with additional physical capability and reserve, allowing them to engage, compete and confront greater challenges with a matching mindset.
Stages of Sport Rehabilitation
Rehabilitation Phase 1 - Control Pain and Inflammation
The first step to rehabilitation lies in ensuring no further harm is caused by resting and offloading any movement of the injury.
This will allow healing to begin and aid in the initial physical responses of Inflammation and pain to injury.
Inflammation is the body's defence reaction against anything harmful and aids in the elimination of damaged or dead tissue, replacing it with the growth of new normal tissue.
Pain management and protection of the injured area to prevent further damage or infection are the priorities.
Rehabilitation Phase 2 - Restoration of Joint Mobility, range of Motion and muscle movement
After allowing time for rest and regeneration of the damaged area, the next stage is a planned program of rehabilitation exercises focusing on the restoration of joint flexibility, range of movement and muscle stretching complementary to the opposite (uninjured) limb.
Note: this is about establishing a range of motions and flexibility and restoration in conjunction with the opposite limb, progressing from non-weight to partial weight bearing or supported movements using for instance pools and assist equipment.
Discomfort will be a natural companion in the initial stages, whilst the absence of any significant pain will positively tilt the balance and momentum of recovery.
Similarly, failing to address and identify pain issues, and foregoing full disclosure between the practitioner and patient / athlete can be detrimental, both physically and mentally and exacerbate the potential adverse physical reactions.
Candour between the athlete and practitioners helps reduce risk and allows for optimum outcomes in a customised recovery programme.
Rehabilitation Phase 3 - Recovery of muscle strength and stamina
The important element of stage three is balance.
Graduated load progression will build up the muscle and endurance of new tissue that does not yet have the required resilience, avoiding overload.
In addition to prescribed performance rehabilitation exercises, there must be a parallel alignment with normal day-to-day movement activities.
For instance, with a tear or sprain of the ACL, there is a need to restore a gradual equilibrium and coordination of the injured and the unaffected limb to re-establish a balanced walking gait without favouring either limb.
Movement and whole-body coordination training starts with gentle but consistent exercise form and progresses to more complex movements incorporating cardiovascular or aerobic training.
Consistent, calibrated exercise form allows measurement of muscle progress and similar exhaustion of the same.
The frequency of workouts is an important factor.
In the rehabilitation schedule, frustratingly so at times for the committed athlete, a longer recovery time between workouts, may yield a greater necessary benefit to skill re-acquisition and return to optimum performance whilst at the same time balancing the strategy with potential detraining impacts.
Rapid return to competition may suit circumstances, but may not benefit longer-term performance potential.
Detraining
The term “Detraining” relates to the effects of insufficient training or no training for a short or long period of time that negatively impacts the individuals physical and physiological status.
Cardiorespiratory Fitness refers to the ability of the heart and respiratory system to supply oxygen during sustained physical activity.
Short-term detraining (less than 4 weeks) impacts negatively on oxygen uptake and blood volume, impairing ventilatory efficiency and endurance performance.
Longer periods of insufficient training negatively impact further on cardiac output (the number of times the heart beats in one minute) and Stroke volume (the volume of blood ejected for each stroke of the heart, whilst at the same time the heart rate actually increases in an attempt to offset the reduction in stroke volume.
Benchmarks
As rehabilitation progresses the welcome feel-good factor experienced by an athlete may make them feel that they are ready to return to competition, but actually mask shortcomings.
As part of a well-managed rehabilitation programme, there must be clearly defined and communicated measurable criteria that contribute to the “Return to competition” status and the rationale behind the criteria.
Some of the criteria might be:
Cardiorespiratory Fitness: evaluation to determine cardiac output and stroke volume and heart rate.
Assessment of Muscular power: the capacity to exert that same force several times in a coordinated manner and in the shortest possible time
Muscular endurance: Sustain repeated contractions against a resistance for an extended period of time. Activities that contribute to muscular endurance include long-distance running, cycling, swimming, circuit training and bodyweight exercises.
Rate of force development (RFD): how fast an athlete can develop force, a measure of explosive strength. RFD is linked to better performances in weightlifting, sprint, cycling, and golf swing performances
Agility: a rapid whole-body movement with a change of velocity or direction in response to a stimulus
Change of direction capacity: a rapid whole-body movement with a pre-planned change of velocity or direction.
Balance: the ability of an athlete to stay in control of their body’s position
Rehabilitation Phase 4 - Recovery of Full Body Coordination - Proprioception
Unthinking, instinctive movement, stemming from an innate spatial awareness and the ability of individuals to identify their joint motion and position of limbs with their eyes closed is known as Proprioception or Kinesthesia.
It’s a term encompassing our judgement and calculation of required or applied force, heaviness, stiffness and viscosity.
It embraces everyday calculations such as whisking a mousse, gently lifting a child, reaching the exact distance to grasp a handbrake, and applying the exact amount of pressure when braking your car or swinging a golf club.
Following an injury, sensory feedback and motor function can be compromised. Naturally, it is automatic to adapt movement and changes in motor patterns in an attempt to compensate for shortcomings that occur through injury, pain and psychological readiness
This disruption can however be restored based on a movement evaluation and identified exercises applied specifically to the diagnosis that encompasses hand-to-eye coordination and balance to restore spatial awareness and neuromuscular control.
Rehabilitation Phase 5 - Recovery of Sport-Specific Technical Movements
Each sport has its own range of movements and exercise forms.
Compare those of a golfer, to someone who plays volleyball, basketball or football and then consider the training variances between the 100-metre sprinter,the 1500-metre runner and the 3000-metre hurdler.
The last stage of recovery is about focusing on the full range of movements specific to the sport they play from basic movements to complex ones.
The key success factors include “proprioception, customisation, evidence-based muscle training program, integrated strategy and planning, prognostication”,(to foretell from signs or symptoms) and are based on technology.
Measurement is a key factor, customisation is specific to the individual, the injury and the mindset.
Prognostication is a term that implies monitoring and constant re-evaluation and ultimately states that the process is one of trial and error and balance to ensure optimum outcomes.
Independence
The latter phases should encourage and promote the confidence and independence of the athlete and remove any residual dependency as they move back into competition and concentrate on performance goals.