Rehabilitation of the Athlete

Abstract

Rehabilitation of an athlete after an injury takes a team approach for a successful return to competition. The five steps of rehabilitation are discussed, including diagnosis, control of inflammation, promote healing, increase fitness, and control abuse. Return to activity can occur once these things are accomplished and everyone is in agreement.

Introduction

The diagnosis and management of sports-related injuries requires a multidisciplinary approach. The sports medicine physician’s responsibilities are to establish a correct diagnosis and direct rehabilitation, enlisting the expertise of physical therapists, orthotists, athletic trainers, and coaches. You can direct the management with five steps that can lead to a return to sports participation.

Step 1: Establish the Diagnosis

Successfully treating an inured athlete requires correctly identifying the injury. Vague diagnoses, such as knee pain or shin splints, fail to clearly define anatomic dysfunction. Whereas diagnoses such as medial tibial stress syndrome or patellar tendonitis assist in more clearly defining the disorder. Diagnosis of most sports injuries requires only a thorough history, physical examination, and selected radiographs.

The history is the most important element in establishing the diagnosis; physical examination and radiographs generally confirm what is deduced from a good history. Ask the athlete questions that focus on identifying the transition that may have contributed to the injury. When did the injury occur? Did the athlete recently start to utilize new equipment? Change training location, intensity? Questions should also focus on clarifying the quality of pain. Identification of the athlete’s training goals and intensity may help reveal an endpoint for rehabilitation.¹

The physical examination seeks to identify the focal problem and uncover contributing intrinsic abnormalities. The entire extremity and/or kinetic chain needs to be thoroughly examined when evaluating a specific injury. Kinetic energy is energy produced by movement; a series of body segments connected by joints can be envisioned as a chain. The kinetic chain thus may be described as the movement of body segments. Failure to identify muscle imbalance patterns and structural misalignment often sabotages a well-planned rehabilitation program.²

The runner who presents with running-related knee pain requires a detailed examination of the knee as well as an examination of the entire lower extremity including the feet. Leg length discrepancies, sacral rotations, hamstring inflexibility, gluteal weakness, and forefoot pronation are only a few of the potential causes.³ The baseball pitcher with shoulder pain needs an examination that includes the lower extremity as well as the trunk, because both are involved in the throwing motion.

As described, the physical examination is biomechanical in its orientation and should include dynamic assessment, because subtle anatomic and physiologic abnormalities not evident on static examination may present when walking, running or throwing. Finally, the examination of the athlete with an injury also requires an evaluation of the equipment utilized (e.g., running shoes, tennis racquets, etc.).

Radiographs aid in diagnosis and can rule out injuries such as fractures, tumors, intrarticular abnormalities, or heterotopic calcification. Only a minority of injuries, those with evidence of major soft-tissue disruption, require more advanced imaging techniques. Electromyographic studies and intracompartmental testing can assist when clinically warranted.

Step 2: Control Inflammation

Although some inflammation is required for proper healing of sports injuries, excessive or prolonged inflammatory response can become self-perpetuating and destructive. Therefore controlling inflammation is one of the primary goals of injury treatment.

The classic approach is RICE (rest, ice, compression and elevation); however, it is becoming standard to utilize PRICEMM, which adds prevention or protection, and modalities and medications to the treatment. Nearly all protocols for managing injuries begin with the athlete abstaining from or modifying exposure to injurious activity. Rest, however, should not necessarily mean a complete refrain from activity. Relative rest protects the injured area while avoiding the consequences of deconditioning and disuse atrophy. To prevent reinjury and ensure better compliance, emphasize what the athlete can do to enhance healing and maintain fitness, rather that what they cannot do. Athletes will often be able to continue some level of training if they follow a modified activity regimen. An example would be pool running for an athlete for whom running on land is contraindicated.

Dr. Crockett with a patient demonstrating the correct form for a forward-walking lunge.

Modalities and medications are fundamental to controlling inflammation and are frequently incorporated into the treatment of sports injuries. By utilizing both agents as adjunct to therapy to assist in pain control, the patient can quickly move to rehabilitative exercise.

Corticosteroids are potent anti-inflammatories, and are commonly used in managing athletic injuries. However, proceed cautiously when using corticosteroids because they are thought to decrease collagen and ground substance production, weaken the tensile strength of tendons, and ultimately result in poorer healing.

Step 3: Promote Healing

Failure to properly rehabilitate an athlete’s initial injury can be an important risk factor for recurrent injury. Often, efforts to control inflammation successfully relieve a patient’s pain, and they prematurely return to activity and are reinjured. Clinicians can ensure a successful return to sport only when inflammation control is used in conjunction with efforts to promote healing.

Promotion of healing involves enhancing the proliferation of vascular elements and fibroblasts to create successful collagen deposition and maturation. This is best accomplished with rehabilitative exercise and cardiovascular conditioning. The goal of rehabilitative exercise is to restore injured tissue to normal or near-normal function. Early exercises enhance tissue oxygenation and nutrition, minimize unnecessary atrophy, and align collagen fibers so they can withstand the sports-induced stresses. Progression through a rehabilitative exercise program can be facilitated by a physical therapist or a certified athletic trainer.

Eventually, successful rehabilitative exercise programs incorporate full-motion strengthening to balance antagonistic forces to allow the athlete to return to their sport.

Step 4: Increase Fitness

People who have tissue that has above normal strength, endurance, and power are optimally suited for the demands of sport. To elevate patient’s rehabilitated normal tissue to above normal levels, introduce fitness exercises and neuromuscular retraining exercises. These exercises involve sport-specific rehabilitative exercises and further general body conditioning.

An athlete can begin sport-specific exercises once they achieve near pain-free range of motion, and strength and endurance tests indicate a return to preinjury state. Sport-specific activities work the athlete’s target tissues, providing neurophysiologic stimulus and redeveloping Proprioceptive skills. Sport specific agility, speed, and skill drills such as plyometrics, eccentric/concentric muscle loading, anaerobic sprints, and interval training coordinate interaction of the athlete’s antagonistic and supporting muscles.

Step 5: Control Abuse

The final step of overuse injury management is to control force loads to the previously injured rehabilitated tissue. Controlling abusive overload requires modifying both intrinsic and extrinsic risk factors that were identified through the patient’s history and physical examination. Control of abusive force loads is best accomplished by: improving the athlete’s sport technique; bracing or taping the injured part; controlling the intensity and duration of the activity; and appropriately modifying equipment

Because abnormal biomechanics quickly promote reinjury, modifying an athlete’s improper sport technique is critical before allowing a return to sport. Bracing and/or taping are used to control abuse during rehabilitation and when the athlete first resumes sport activity. Counterforce bracing helps constrain an athlete’s muscle balance.

Modifying equipment requires paying attention to shoes, sport-specific equipment, and playing or training surfaces. Abnormalities in an athlete’s foot biomechanics can contribute to numerous lower extremity injuries. Attempts to correct the abnormalities through rehabilitation, proper footwear, and orthotics should be made.

Training errors, specifically those of excessive intensity and duration, represent the principal risk factors for injury. The clinician must emphasize that more is not always better. Encourage athletes to follow basic training principles of progression and periodization. Education regarding that overtraining is not only a precipitator of injury, but also promotes fatigue and decreased performance.

Return to Activity

Traditionally, athletes have been allowed to return to activity when they can demonstrate full range of motion and when the injured extremity showed 80% to 90% of the strength of the uninjured extremity. This is, however, the minimum requirements. Before returning to the activity, physicians should also focus on two questions:

1. Does the athlete demonstrate sports-specific function?

2. Is the athlete psychologically ready?

When the athlete, trainer, coach, and physician are satisfied that the answers to both are “yes,” the athlete can safely return to full activity.

Biography

Boyd Crockett, MD, practices physical medicine, rehabilitation, and sports medicine at Southwest Spine & Sports Medicine in Springfield.

Contact: boyd.crockett@coxhealth.com