Rehabilitation Procedures

Rehabilitation procedures ensure that athletes who return to play do so only when they are ready and it is safe to do so. If athletes return to play too quickly, they can increase the chance of re-injury. Each athlete will recover from an injury at different rates. Therefore, there are no specific timelines for recovery. As with all soft tissue injuries, it is important to apply RICER immediately to facilitate the recovery of the injured site. For hard tissue injuries, rehabilitation will involve weeks of immobilisation of the injured bone.

There are a number of procedures, which are necessary components of rehabilitation.

Progressive mobilisation

After applying RICER principles, the objective should be to encourage painless movement of the injured site, to reduce the likelihood of seizing and the development of scar tissue.

Mobilisation should be gentle to begin with and progressively increase as confidence builds along with strength at the injured site. Throughout this stage, it is important to continue to apply ice and compression to help reduce swelling and to prevent waste, like fluid, from building up. The athlete is also encouraged to gently stretch out the injured site to lengthen the muscle fibres and improve joint mobility. Remember, pain is an important indicator and the athlete should cease movement as soon as they feel any discomfort.

Graduated Exercise (Stretching, conditioning, total body fitness)

STRETCHING

Loss of flexibility can occur when there is injury to muscle and connective tissue due to lack of use and reversibility of training. It is therefore important to stretch muscles so that they can regain their elasticity, increasing flexibility. Stretching should begin 72 hours after the injury has occurred. This allows time for any swelling to reduce, meaning active rehabilitation can begin.

Stretching exercises reduce the amount of tension in the muscles, increase tendon and muscle strength, increase the range of movement and allow for greater blood flow, or circulation. While static stretching is encouraged, PNF is the most appropriate method for athletes who want to recover their range of movement. Athletes should conduct stretching after the use of heat and massage to stimulate the blood flow into the area of the body that has been injured.

CONDITIONING

Conditioning activates and increases the size and endurance of muscles. Without conditioning there is the likelihood that the muscles will remain passive and decrease in size; a process called reversibility. Depending on the level of pain, athletes may use the overload principle, progressively increasing the load on the body during rehabilitation and recovery.

Before conditioning, athletes should perform gentle strengthening exercises, including isotonic, body weight holds and exercises, or gentle static holds. All exercises should be performed without pain. The purpose of conditioning is to improve the muscular strength and endurance of the injured site. As pain and swelling reduces athletes can introduce additional exercises to their routine, like weight bearing activities.

It is important to develop the proprioceptive abilities of the athlete during this stage. The athlete needs to retrain their body so it instinctively and correctly responds to sport specific situations and scenarios. A conditioning program also needs to contain an element of specificity, targeting general cardio-respiratory fitness and increasing strength, power and muscular endurance around the injured site.

TOTAL BODY FITNESS

Training for total body fitness involves use of the progressive overload principle. This must be applied to the muscle groups and energy systems being used so that the following adaptations are regained before competition:

– muscle hypertrophy

– strengthening of the tendons/ligaments

– improvements to the blood flow around the injured area; increased capillarisation

– greater elasticity of fibres

– greater joint mobility

– confidence in movement

– balance and coordination

If an athlete is not able to complete a maintenance program, reversibility may occur. Depending on the injury location, an athlete may maintain fitness levels through cross training techniques. For example, aerobic activities such as swimming, cycling and running, can supplement other activities to help maintain aerobic fitness levels. If an athlete has a lower leg injury, they may be still able to complete upper body strength work and controlled swimming exercises.

Training

Once the athlete is confident that they have regained strength, fitness and flexibility around the injured site, modified training can resume. The athlete should only commence competitive/contact training under the recommendation and supervision of a team doctor or physio. If given the all clear, there is a need to progressively increase the physical demands on the athlete, making sure to minimise the risk re-injury. There needs to be constant communication between medical staff, the coach and the player to make sure all parties understand how the athlete is progressing with rehabilitation. Before returning to play, an athlete should be able to complete a full training session without experiencing any pain.

Use of heat and cold

In first 72 hours after injury occurs, or following a rehabilitation session, it is important to ice the area to aid in the removal of waste products and reduce swelling at the site. After the initial 72 hours, heat can be applied to the injury to increase blood flow and remove the build-up of any waste products. The flow of blood delivers fresh nutrients to the site, helps prevent the development of scar tissue and relaxes muscles, which may be sore and tight.

Reference: Improving pdhpe

Return to Play

Athletes will generally want to return to their sport as soon as possible. Care must be taken, through rehabilitation procedures, to ensure that they only return when they are fit and ready to minimise the risk of re-injury. This process involves discussions between the player, coach, team doctor or team/individual physiotherapist to ensure that all parties are satisfied that the athlete is ready to return to play.

Indicators of readiness for return to play (pain free, degree of mobility)

Before an injured athlete can return to normal competition, they need to undergo testing to ensure that they are both psychologically and physically prepared. Active and effective rehabilitation will ensure the healing process has resulted in a marked improvement to the injured site. Testing should demonstrate that the athlete has a full range of movement at the injured site, so that the athlete can push the recovered part of the body to a high intensity in competition. The athlete should have also developed improved strength and flexibility, which will be evident after basic skill and fitness testing is conducted.

Confidence is important for the athlete as they need to be able to put their body in situations that may challenge the injured site. If they are not confident, they increase the chance of re-injury or poor performance.

Monitoring Progress (Pre-test and post-test)

It is important to monitor progress throughout the rehabilitation phase of an injury. Comparing results from pre-tests to those of test conducted after the injury was sustained will reveal whether any progress has been made. For example, comparing the results of pre-testing, determined Range of Motion (ROM) with those obtained after injury rehabilitation has taken place.

Before returning to competition, athletes will usually need to test the injured site by completing a series of sports specific exercises. For example, a soccer player returning from a hamstring strain may be required to complete activities which focus on speed, change of direction, intense movements and striking. Athletes need to be able to complete these activities without pain and at 100% effort to match a game situation and demonstrate they are ready to return to play.

These tests are designed to assess the power, strength, flexibility and proprioception of the recovering athlete. If the activity cannot be completed in a similar fashion to how it was prior to injury, then the athlete should continue rehabilitation.

Psychological Readiness

In order to be considered fit for play and athlete must possess confidence in their abilities and positive outlook. Mental attitudes contribute significantly to recovery and the prevention of re-injury.

Many athletes want to return to their sport as soon as possible when they injure themselves. Others often feel externally pressured to play due to the expectations of media, sponsors or club directors, even though they don’t feel confident themselves. Both of these situations can often result in re-injury.

There needs to be open communication between the player, coach and sports psychologist to ensure that the athlete is mentally ready to compete again. Ideally an athlete must demonstrate a healthy balance of motivation, common-sense and a self-awareness before they can safely return to the game.

Specific Warm up Procedures

After injury elite athletes will develop specific warm up routines to minimise re-injury. It may need to focus on the injured site to ensure that there is adequate blood flow. They may also incorporate mental exercises to build confidence and reassurance. For example, an AFL player who is returning from a hamstring injury will spend more time warming up that area of his body, completing additional hamstring and quadriceps stretches. It is important that mentally, the athlete knows that they have warmed up in a safe environment and pushed that particular muscle group past what it may be expected to go through in the field. This will reassure the player that they have recovered and are ready to play.

Return to Play Policies and Procedures

The decision to return to play will be impacted by the severity of the injury. Individuals who do not play at an elite level are encouraged to make a decision based on discussion with their physiotherapist, trainer or doctor to ensure they are completely recovered. Parents will often make this decision for child athletes, in consultation with the medical professional.

At the professional level, there are different actions. which must be completed before an athlete is considered ready to play again. These types of protocols may include:

– consultation with appropriate medical professionals

– review of x-rays/ scans and medical reports

– rehabilitation discussions and preventative strapping advice

– a fitness assessment, which includes specific testing

– participation in a range of sport specific movements as part of an injury skills test

Depending on the sport and the level of competition, different coaches may draw on their own experiences to create specific criteria for individual athletes to determine whether they are fit for competition. They may have a system which allows the athlete to return via a less stressful environment, which will put less stress on the injured site, such as assigning them to a reserve grade game in soccer or rugby league. This type of strategy will often be impacted by the type of injury as well as the timing of the competition.

Each sport should have a return to play policy which addresses the different requirements of the athlete and coach, prior to return after an injury. These include:

– Ensuring the athlete is safe and functional

– Identifying the potential risks to safety of others competing

– The requirements of the sport and whether the injury impacts this

At all levels, it is important that documents are kept and recorded to cover liability in case of re-injury.

Ethical Considerations (e.g. pressure to participate, use of painkillers)

Elite athletes often feel pressured to return to play as soon as possible. They may be trying to maintain a particular position on the team, fighting for a new contract or expected to play during a big game.

This pressure often comes from external sources like sponsors, fans and the team, which may force the athlete to return to the sport before they are ready. Athletes may also experience internal pressure caused by their own expectations about their success, motivation, ambition and self-worth. Unfortunately, these factor may lead athletes to use painkillers or other drugs in an effort to give them the temporary energy or relief they need to play their sport.

Younger athletes are frequently pressured by parents or coaches to perform, which can result in additional injury if they aren’t provided with an adequate recovery period following the initial injury.

Some injuries, like concussions, require the completion of compulsory documented procedures before an athlete can return to play. These kinds of regulations can protect athletes. The pressure to return to play, even a week early, can often result in further injury.

Athletes face a range of external and internal pressures, which may force them to return to play before they are ready. For example:

– Financial pressure

– Drive to win

– Sponsors

– Fans

– Friends and Family

However, the main priority of every athlete should be to maintain their health, safety and wellbeing.

Reference: Improving Pdhpe