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REHABILITATION OF SPORTS INJURIES

by Rose Macdonald BA, MCSP, MCPA, SRP, Director, Sports Injury Centre, Crystal Palace National Sports Centre, London

First aid treatment of sports injuries, particularly the control of swelling, is the most critical part of a rehabilitation programme. The author explains how subsequent exercises need to be varied according to the age, sex and sport of the athlete, and gives some examples of specific rehabilitation programmes.

The current interest in sport is presenting the general practitioner with a wide variety of sports-related musculoskeletal problems. These may vary from a mild ligament sprain to the complex problem of an anterior cruciate ligament rupture. Whether the injury be simple or complex, an accurate diagnosis is essential, followed by comprehensive treatment and rehabilitation.

Initial management

Initial first aid and management techniques are the most critical part of any rehabilitation programme. The initial management has a significant impact on the course of rehabilitation. Immediate first aid for any injury should follow the PRICER principle:

Protect and prevent further damage (splint or bandage) Restrict activity and refer on for assessment
Ice to reduce pain, promote vasoconstriction, and control haemorrhage and oedema
Compress to reduce the amount of space available for swelling
Elevate to eliminate gravitational blood pooling, and assist drainage back to the central circulatory supply
Rehabilitate to restore normal function and maintain fitness

The injured sports person should also be advised of the things to be avoided after an injury (the HARM principle:

Heat must not be applied to the injury, as it increases blood flow
Alcohol must not be drunk, as it causes vasodilation
Running must stop for the present
Massage must not be applied initially, as it will cause further damage to friable tissue

Swelling is one problem that all injuries have in common. It produces increased pressure on the injured area, which causes pain, and pain inhibits movement.

Once swelling has occurred, the healing process is retarded and the injured area cannot return to normal until the swelling has gone. If the swelling is controlled in the acute stage of injury, the rehabilitation time will be significantly reduced.

Promoting healing

Once the injury occurs, the healing process begins. If the injured structure is not protected from further damage and rested appropriately, the healing process does not have a chance, and rehabilitation is prolonged.

Factors that may impede healing include oedema, haemorrhage, muscle spasm, muscle atrophy, infection, age, health and nutrition. Injured tissue takes time to heal, so the following management principles should be followed, to promote healing of sports injuries:

control inflammation with non--steroidal anti-inflammatory drugs
reduce the training load, e.g. relative rest
correct biomechanical faults
stretch and strengthen the injured structure
correct predisposing factors such as coaching and training errors, e.g. sudden increase in training, inappropriate shoes, hard surfaces

The length of time that tissues take to heal after injury varies, as follows:

skin, 2-3 weeks
muscle, 4-6 weeks
tendon, 6-8 weeks
ligament, 6-8 weeks
bone, 12-16 weeks
nerve, 12-18 months

This length of time may be influenced by various factors. For example, by minimising secondary complications, healing and repair time can be accelerated, resulting in a quicker return to sporting activity. However, if critical care is delayed or inappropriate, recovery can be significantly delayed.

The figures above refer only to healing and repair time, and not time necessary for the athlete's full rehabilitation.

Activity too soon after injury will delay the healing and repair process, and may result in a permanent functional disability (e.g. recurring ankle sprain or chronic hamstring strain.)

For every week an athlete has been away from activity as a result of injury, approximately one week of rehabilitation will be required, assuming that he or she is on a well-designed programme. Failure to rehabilitate an area after injury increases the chances of further damage.

The specialist must have a sound knowledge of the healing process, the various stages of healing, and approximate time for each stage: inflammatory; fibroblastic; maturation. The process is a continuum and the phases overlap.

Rehabilitation programmes

The aims of rehabilitation are to:

control inflammation and pain
restore full range of motion and soft tissue extensibility
restore muscular endurance and strength
maintain cardiovascular endurance
retrain sport-specific skill patterns

All muscles of the injured limb need to be exercised, concentrating on the weaker muscle groups.

Tailoring the programme to the individual

Different strengthening and stretching methods are required for each age group. When prescribing a rehabilitation programme, it is very important to be aware of the physiological changes and different musculoskeletal problems pertaining to the different groups (e.g. growing children, osteoporotic female athletes, menopausal women). Older people suffer from decreased flexibility, as well as poor balance and cardiovascular endurance, so it is necessary to remember this when prescribing conditioning exercises for them.

Good communication between the physiotherapist and the injured sports person is essential. For example, the response time to treatment in the older athlete is unpredictable, as the healing time is variable in such patients.

Graduated rehabilitation

To strengthen a muscle after injury takes time, and healing muscle has large amounts of scar tissue, which must be stretched. A graduated regime may be necessary, as follows:

a gentle stretch held statically
isometric exercises for specific muscles to aid fluid absorption
isometric exercises with increasing loads within the limits of pain
isotonic exercises with and without load
progressive resistance exercises for strength
proprioceptive regime, e.g. standing on one leg

Biomechanical imbalances and anatomical malalignments must not be forgotten. Exercises must be adapted to the needs of the athlete for his specific sport, and a logical progression is important in order to minimise the potential for re-injury.

Strength and flexibility exercises must be combined in order to maintain full range of movement about the joints. The athlete must be encouraged to continue this programme at home. Water training is often used when the athlete needs to maintain cardiovascular fitness while maintaining his sport-specific training patterns (e.g. running) without adding further trauma to the damaged tissues. The land training programme is performed in the pool wearing an aqua-jogging belt.

The rehabilitation programme should place increasing loads on the injured part, and the athlete should be confident that he/she has been put in a situation that is more stressful than competition. Hamstrings and adductors are susceptible to breakdown with sudden accelerating and decelerating activities, therefore these should await the final stages of rehabilitation.

Specific training for the sport
Strength training

Muscles become stronger when made to work. Overall muscle strength is desirable, but specific muscles must be strengthened for particular sports (e.g. the shoulders of gymnasts). Strength training must be tailored to individual needs; the most common methods used are progressive resistance exercises or weight training. High numbers of repetitions with low weights are more desirable to begin with, as strength and endurance are combined.

Development of endurance protects against injury by preventing fatigue, and must be achieved slowly. Injuries in all sports are more likely to occur when the athlete is training. Shorter, intense sessions avoid fatigue.

Taping and strapping

Taping and strapping play an important role in the prevention, treatment, and rehabilitation, of sports injuries. The correct application of tape provides support and protection to injured soft tissue and joints, without limiting function unnecessarily. Tape reinforces the normal supportive structures in their relaxed position and protects injured tissues from further damage. Taping and strapping is not a substitute for treatment and rehabilitation, but is an adjunct to the total injury care programme. Taping and strapping a joint after injury allows functional activity during rehabilitation.

Stretch tape is used in the early acute stage, together with padding, to compress the soft tissue and contain the swelling. However, the tape must not be applied until a full assessment of the injury has been made.

Non-stretch tape is applied to protect and support the injured ligaments/capsule, by restricting the range of motion and supporting them in their shortened position for optimal healing and repair.

Multi-disciplinary team approach

Prompt assessment and diagnosis is vital in the successful treatment and rehabilitation of sports injuries. Sports enthusiasts suffering from either a recent injury or a recurring problem can benefit from the expertise of a specialist team.

A multi-disciplinary team approach is ideal and may consist of some or all of the following: general practitioner; chartered physiotherapist; sports psychologist; sports scientist; sports nutritionist. Cross-referral may take place within the team in order to rehabilitate the "whole" person and not just the injured part.

The general practitioner is the key person as he or she knows the patient's full medical background and is the one who refers the patient on to a consultant if necessary.

Chartered physiotherapists are trained in the techniques required for the successful treatment and rehabilitation of sports injuries, by the use of electro-therapeutic techniques, mobilisation and manual therapy, maintenance and development of general fitness, and education of the competitor in training, fitness and injury prevention.

The aim of the specialist team is to return patients to full fitness and to sport in the shortest possible time by careful assessment, correct diagnosis, effective treatment by skilled physiotherapy, and continuous reassurance.

Individual rehabilitation programmes

Individual programmes must be planned and implemented for each patient. A typical programme would include general and specific exercise in the gymnasium, taping, strapping, use of ice and the whirlpool, and a home exercise programme. Other facilities may also be used by patients for rehabilitation, for example, swimming pools for training in water and different running terrains (grass, hills, track, stadium steps) to condition athletes before their full return to sport.

Handouts should be available for patients, outlining the immediate care of common injuries, together with leaflets on stretching, strengthening and flexibility exercises for warm-up/warm-down regimes, and on conditioning regimes prior to return to sport.

Knee rehabilitation

A pulley regime can be used for knee rehabilitation. The routine is begun with a wight of between 2.5 and 5 kg, depending on the muscle strength of the patient (a rubberised Cliniband or Theraband may be substituted for the pulley).

The legs are exercised through hip flexion, extension, abduction and adduction, using all four muscle groups around the knee: the quadriceps; hamstrings; abductors (gluteus medius and tensor fascia lata); and adductors (gracilis adductors longus, brevis and magnus).

The routine begins with three sets of 10 repetitions and progresses to a maximum of three sets of 25 repetitions. As the weight is gradually increased (the rubber band doubled), the repetitions are decreased back to three sets of 15 and progress to three sets of 25 again. The greatest weight used in the straight leg routine is 12.5 kg. When the patient has full flexion of the knee, hamstring curls are added to the routine. Both legs are exercised together to begin with, then one leg at a time.

Stretching/strengthening the calf muscles

Care must be taken not to neglect the calf muscles during this time. Therefore a routine of stretching and strengthening exercises for the calf muscles and achilles tendon is incorporated into the programme.

The patient stands on an inclined board or rocker in full plantar flexion (toe stand). The heels are then lowered into dorsiflexion using body weight to stretch the achilles tendons and calf muscles. The heels are raised again to full plantar flexion, using the body as the resistive force. This exercise is performed with both legs initially, then unilaterally. As strength increases, each leg is exercised for three sets of 10 repetitions, building up to five sets of 10. Small weights may be added to the shoulders as strength and endurance increase. Speed, number of sets of repetitions, and weight, are increased to patient tolerance while symptom free. Wobble boards and bouncers are also used for proprioception of the knee and ankle.

Before returning to sport, the patient should be able to run, skip, run figures of eight, push off, cut, change direction, and land on one leg. At this stage, the coach takes over, acting as the bridge between the clinic and the playing field.

Returning to sport

Before the athlete returns to sport, he/she should be assessed by the physiotherapist or doctor. He/she must have normal joint, muscle and tendon function. No athlete can be properly assessed on an examination couch. Partially healed injuries are re-injured if subjected to stresses that they are incapable of withstanding.

The safe return to sport depends upon:

gradual and progressive reintroduction to sport by the coach
development of sport-specific skill patterns
maintenance of the cardiovascular training programme
mental and physical re-education

An athlete must be psychologically ready to return to sport. Having understanding friends, family and team mates, is important in motivating athletes to continue with prescribed rehabilitation programmes until fully integrated into the team again.

Prevention of injury
Warm-up exercises

Muscle and tendon strains can be minimised by warming up before activity. Care must be taken to warm up properly by raising muscle and deep body temperature to the most effective level.

A good warm-up prepares the body for activity and should include activities that slowly raise the heart rate, flex and relax muscles, and move joints through a broad range of motion by stretching. The warm-up lubricates joints and increases the blood supply to the muscles, thus making the muscles and connective tissue that surrounds the joints more supple in preparation for more strenuous activity.

If thrown into vigorous activity without adequate warm-up, the body's natural stiffness and resistance will lend itself to injury. However, excessive warm-up leads to over expenditure of energy and exhaustion.

Cool-down exercises

Cool-down with stretching is also very important. Muscle cells contain waste products, which must be flushed away. Lactic acid is removed from the tissues twice as fast by an active warm-down. Slow tapering off keeps the heart rate and blood flow from dropping too quickly. As the muscles are warm, they will adapt to stretching more easily at this stage.

Preventing stiffness

Stiffness may affect athletes at times of heavy or unaccustomed training, and some athletes are more prone to stiffness than others. Regular slow stretching during the warm-up helps to prevent stiffness, and repeated again after activity it minimises subsequent stiffness.

Stiffness in muscles, tendons, ligaments, and joint capsules, may be caused by unaccustomed exercise, muscle overload, and changes of training type or running surface. The most effective remedy for stiffness is to train regularly and specifically for the event and to avoid post-exercise chilling.

Conclusion

Rehabilitation of the sports person is different to that of the non-sports person. The sports person has the pressure of training and competition to deal with, and is anxious to get back to training as soon as possible. It is important that fitness be maintained while the injury is healing. If a previous injury has been sustained, there is a high risk of recurrence, especially if the athlete has returned to sport too soon without adequate rehabilitation.

If proper rehabilitation is not undertaken, the athlete may be competing too soon with instability, proprioceptive disturbance, and muscle weakness. The aim of rehabilitation is to restore full function and enable the sports person to return to his or her sport as soon as possible.

Practical points

Accurate assessment, comprehensive treatment and rehabilitation are necessary for the successful management of sports injuries; first aid treatment can be critical
Swelling, common to all injuries, produces pain, inhibits movement and retards healing; control of swelling is a major first aid principle
Activity commenced too soon after injury delays healing and repair
Allow one week of rehabilitation for every week that an athlete has been away from activity
Rehabilitation programmes need to vary according to age and sex