Rehabilitation Of Sports Injuires

Rehabilitatio n of Sports   Injuires  

 

 

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Introduction

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Principles of rehabilitation

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Key concepts

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•

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Team approach

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Diagnosis

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Acute injury management

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Drugs

Management ○

Passive physical treatments

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Active physical treatments 

Strengthening exercises



Flexibility



Endurance



Proprioceptive retraining



Functional training

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Psychological

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Biomechanical factors

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Return to sport

Rehabilitation of four common injuries. ○

Tennis elbow

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Sprained ankle

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Hamstring

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Stress fractures

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Complications of rehabilitation

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Prevention

‘Life is movement, movement is life’. Aristotle Introduction Rehabilitation is a generic term for the comprehensive treatment of injury and/or medical conditions. It has active and passive elements. It focuses upon the whole person not just the injury and aims to restore the greatest possible degree of function in the shortest possible time. The factors implicated in the cause of injury should be addressed to prevent injury recurrence. Three concepts help with the understanding of the rehabilitation process these are impairment, disability and handicap. Injury causes an individual an impairment. This is the injury at the tissue level e.g. ruptured medial collateral ligament of the knee. Impairment usually causes a disability This is a loss of function e.g. walking with a limp and unable to run. This in turn may cause a handicap this is an individuals inability to perform tasks or engage in activities. e.g. the professional footballer is unable to compete for the rest of the season due to the knee injury which causes loss of playing time, reducing his income and prematurely ending his career. This causes some reactive depression. From this example the need for the physician to consider the medical, physical, psychosocial, vocational and leisure requirements of the injured athlete is apparent. The areas covered are 1.

the principles of rehabilitation.

2.

treatment modalities

3.

specific examples

4.

complications of inadequate or incorrect rehabilitation

5.

prevention

Principles of rehabilitation The process of athletic injury rehabilitation aims to minimize tissue damage and allow a safe return to activity. It is based on the science of tissue healing, knowledge of joint biomechanics, physiology of muscular strength and endurance, and the neurophysiological basis of skill retraining. Successful programs are based on an understanding of these constraints, which, when properly applied, permit the progressive activity of joints and

muscles. Muscular strength, endurance and power are redeveloped while flexibility and cardiovascular fitness are maintained. Precipitating factors are identified and addressed to minimize reinjury. (1) To understand, grade and treat injuries the physician needs to identify the tissues involved. This chapter focuses on muscle-skeletal injury and rehabilitation of bone, ligament, muscle, tendon, connective tissue and neuromuscular structures combining to produce coordinated, purposeful movement. The treatment of other injuries is covered in relevant chapters. The healing process involves inflammatory, repair and remodeling phases. There are detrimental effects of immobilization, muscle wasting and weakness and subsequent joint damage. This leads to further immobilization and reflex inhibition ‘a vicious circle’. Early mobilization is usually indicated. Lack of motion of joints results in shortening of capsular and other connective tissue structures supporting the joint, loss of lubrication and alternating compression between joint surfaces deprives articular cartilage of nutrition.(2) There are detrimental systemic effects of immobilization, these begin within hours and become clinically important within days. They include cardiovascular deconditioning, nervous system depression, skin sores gastrointestinal complaints (constipation), thromboembolic genesis, bone resorbtion and respiratory impairment.(3) Thus the expression ‘MOVE IT OR LOSE IT’ An understanding of the sport or activity is required, many injuries are sport specific and communication is enhanced if the physician has some basic knowledge of the sports requirements. ‘Profiling’ is a concept that matches an individuals physiognomy with the type of athletic activity and in team sports their role. 1 Kulund ‘The Injured Athlete’ Lippincott 1988 2 C Hubley-Kozey et al.1994.Rehabilitation Principles and Techniques.In JC Delee et al Eds Orthopaedic Sports Medicine Chapter 6 p 184-207.Saunders Philadelphia 3 Krusen’s Handbook of Physical Medicine and Rehabilitation 3rd Ed Saunders1971 Key concepts Team Approach Rehabilitation is facilitated by a team approach. The basic team comprises in order of importance •

The injured athlete.

•

The physical therapist- physiotherapist have the most scientific training (other types

include masseuse) •

The doctor.

•

Others; orthotist, brace maker, strapper, coach, exercise trainers, dietitian, psychologist, dentist, nurse, first aid personal, peer group, family and friends.

Diagnosis

History

present injury, past, athletic, social, family

Examination

and psychological histories where required including measurement of impairment and function, comparison with unaffected limb

 

Investigations

and review of biomechanical factors.   this may include specific functional tests, pathology, radiology and nuclear medicine

Problem list

investigations where appropriate particularly if the injury is complex or severe(4).

 

  Acute injury management (Table 1) Begins immediately and can be performed by the athlete or any other capable person. This phase lasts the first 24-48 hours. It consists of protecting the individual from further harm, resting, and icing the injury. Compression and elevation are used to minimize edema and haemorrhage and drugs are used for analgesia, anti-inflammatory properties and muscle spasm relief. Acute injury management is summarized by the acronym P R I C E. Occasionally more extensive treatment or surgery is required.

4 Stolov W ‘Evaluation of the Patient’ in Krusen’s Handbook of Physical Medicine and Rehabilitation 3rd Ed Saunders1971

Drugs In general the authors feel that drug use should be minimized and the other components of injury management emphasized. Drugs used in rehabilitation of sports injuries are of four main groups. 1. Analgesics - paracetamol, codeine, opiates and local anesthetic agents.

2. Anti- inflammatory medications are used extensively and have analgesic properties as well as causing moderation of the inflammatory response to injury. A short course of 3-7 days can be useful. Compliance is better with once or twice daily dosing. Topical and parental antiinflammatory medications are now available. Gastric ulceration, hypertension and renal impairment are among the side effects. 3. Anti spasmodics and sedatives are utilized to reduce muscle spasm and consequent pain, stiffness and immobility in the first 48 hours. They also induce drowsiness and can aid sleep. Benzodiazepams are used with caution as they affect balance, coordination and judgment(5). 4.

Corticosteriods are usually used in chronic injuries. They have anti inflammatory,

immunological and metabolic effects. They are injected intra-articularly or into connective tissue around tendons e.g. in subacromial bursitis. Their efficacy has been established(6). There are severe potential complications such as septic arthritis and tendon rupture these agents should be used by experienced practitioners only. Do not use on the Achilles tendon(7).

5 Goodman and Gillman The Pharmacological Basis of Therapeutics 8th Ed Pergamon Press 1990 6 Nelson K Briner W Cummins J Corticosteroid injection therapy for overuse injury Am Fam Phy 1995 52(6) 1811-6 7.Shrier I Matheson G Kohl H Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med 1996 Oct 6(4) 245-250

Management Passive physical treatments Ice

)

Heat

)

Ultrasound

)

T.E.N.S.

)

Laser

)

Manual Therapy

used alone or in combination

)

Ice has beneficial effects in the acute and intermediate phases(8). Cold decreases spasm and slows nociceptor nerve conduction. Once swelling and pain have diminished sufficiently, ice is combined with active and passive range of motion within pain tolerance. The ice is used both prior to and during the therapeutic exercise session. This is done for 20-30 minutes twice a day. In between the injury site is protected. Induce analgesia with ice for 20 minutes, exercise (static stretch, isometric contract, static stretch), rest 30 seconds and repeat (2-3 times) several times per day. Once the effects of swelling and pain have subsided and the athlete has progressed to more vigorous exercise and functional activity, the ice is used for 20-30 minutes after the therapeutic exercise bout. Ice can cause burns and superficial nerve

palsies (peroneal and ulnar) Ice pack; Plastic bag, crushed ice, tea towel. Caution should be exercised with Gel packs which freeze below 0 Centigrade. These should be wrapped in toweling. Heat causes vasodilatation (increased delivery oxygen, nutrients and immune mediators) and increased metabolic rate, altered pain sensation, increased collagen extensibility, better nutrition and decreased sensitivity to muscle stretch(9). Acute use helps relieve muscle spasm. Most useful for chronic inflammation, joint stiffness, pain syndromes. May cause increased edema and local burns and should be supervised by the physical therapist. Modern use of heat relies on hot packs 40-70 degrees applied for 20 minutes in conjunction with range of motion exercises. The widespread use of rubifactents to cause peripheral vasodilatation and local heating is not recommended due to the relative difficulty in controlling timing and dosage.

8 Hillman and Delforge The use of Physical Agents in the Rehabilitation of Athletic Injuries Clinics in Sports medicine 4/3 July 1985 9 Lehmann J Therapeutic Heat and Cold 3rd Ed. Williams and Wilkins 1984

Ultrasound. High frequency soundwaves 0.8- 1.1MHz, produce heating at fascial planes. When pulsed at low frequency ultra sound produces a mechanical effect. Together they produce an analgesic and anti-inflammatory effect by increasing local perfusion and metabolism(1).Thrombolysis is aided and there is a role in haematoma treatment(11). There are complications of overzealous or incorrect treatment. Usually employed after the acute phase.(12) TENS transcutaneous electric nerve stimulation produces analgesia and is used extensively in chronic pain syndromes(13). Works via spinal gate mechanism and direct effects on nociceptors. Indifferentual is a form of TENS in which alternating electrical stimulation is used to produce various levels of muscle contraction. This reduces the edema and helps minimize disuse atrophy. There is some evidence that it has antispasmodic action in spinal injury patients(14). Laser Cold laser is used for small localized lesions (e.g. long head biceps strain) It is claimed to reduce pain and spasm and have beneficial effects on local metabolism. Evidence exists for alteration of nerve conduction(15) but is absent for clinical effect in well controlled in vivo studies(16).

10.Gam and Johannen Ultrasound therapy in musculoskeletal disorders: a metanalysis Pain 1995 Oct 63(1) 8591 11 Luo et al Transcutaneous ultrasound augments lysis of arterial thrombosis in vivo Circulation 1996 Aug 15 94(4) 775-8 12 Falconer et al Therapeutic ultrasound in the treatment of musculoskeletal conditions Arthrit Car Res 1990 June 3(2) 85-91 13 Wall and Melzeck Textbook of Pain 2nd Ed C-Liv 1989 14 Goulet et al Effects of transcutaneous electrical nerve stimulation on H reflex and spinal spasticity Scand J Rehab Med 1996 Sep 28(3) 169-176 15 Baxter et al Effects of low intensity infrared laser irradiation upon conduction in the human median nerve in vivo Exp. Physiol 1994 March 79(2) 227-34 16 Mokhtar et al Double blind placebo controlled investigation of the effect of combined phototherapy/low intensity laser therapy upon experimental ischaemic pain in humans Lasers Surg Med 1995 17(1) 74-81

Manual therapy. This differs from the above modalities in that it requires the therapists to use their bodies on the patient. Manual therapy encompasses all forms of massage, mobilization, manipulation, traction and neural stretching. The ultimate manual treatment consists of surgery. The individual techniques and combinations applied vary and are beyond the scope of this chapter. Manual therapy is the most ancient form of medicine the ‘laying on of hands’ Several practitioner groups make claims that are unscientific and misleading. The authors recommend that athletes be guided to therapists who have scientific training, experience in sports injury and who can work in a team. There are potential risks with manual therapy, particularly rotational spinal manipulation which has caused disc prolapse, corda equina lesions and vertebral artery dissection (17,18). There are clear benefits in reduction in muscle spasm and edema, relaxation, flexibility and increased joint range of motion from manual therapy. There is also a placebo effect in some patients. Psychological benefits of manual therapy are often observed.

17 Padua et al Radiculo medullary complication of cervical spinal manipulation Spinal Cord 1996 Aug 34(8) 48892 18 Assendelft et al Complications of spinal manipulation: a comprehensive review of the literature J Fam Pract 1996 May 42(5) 475-80 19 Maitland G Peripheral Manipulation 2nd. Ed. Butterworths 1987 20 Knapp M. Massage Krusens Handbook of Physical Medicine and Rehabilitation 3rd Ed. W.B. Saunders 1982

Active physical treatments Active physical treatment is the foundation of the rehabilitation process. When an injury occurs immobile muscle rapidly atrophies, connective tissue contracts and detrimental joint changes occur. Active physical treatment requires the interest and compliance of the athlete to minimize injury consequences and return to activity. Strengthening exercises (Fig 1-14). These aim initially to minimize disuse atrophy, increase circulation and maintain muscle condition. As healing continues gains in strength, control, co-ordination and endurance facilitate recovery. There are several types of strengthening exercises and these are combined for maximum effect(21,22). Isometric These exercises are conducted without movement across the joint on which the muscle acts. There are two program types prolonged contraction involves a 20 - 30 second contraction performed 10 -20 times with a 20 second break. These can be performed from the acute phase of injury up to 10 times per day. Basmajian (21) recommends brief (5-6 sec) repeated isometric maximal (added weight) exercises with a 20 sec delay. This minimizes cardiovascular stress (hypertension) which has been observed with prolonged isometric exercise. Isometric exercise can be performed with the joints in various angles and achieve improved strength of muscle. Isotonic In which muscle contraction moves a joint through a range of motion. Thus if the muscle shortens while contracting (e.g. biceps curl) it is termed a concentric contraction. The act of lowering a weight from height (e.g. lowering a biceps curl back to the start position) is termed eccentric as the muscle is lengthening while contracting. Daily progressive resistance exercise (P.R.E.) using weights or other resistant devices is prescribed and begins after the acute phase. Multiple repetitions are used and the number and resistance can be varied(22). The tempo or rest periods can also be progressively altered. Careful instruction and supervision is required. Typical examples are provided later. A variety of machines have been designed to improve strengthening throughout the joint range for different muscle lengths. One type is a command system with increased weight at mid range and reducing at full extension and flexion (Nautilis) Various machines have been developed to perform isokinetic exercise. This allows constant velocity with variable resistance as the muscle move the joint through its range. An example is the isokinetic dynamometer machine which was originally designed for rehabilitation of knee injuries. It can be applied to any joint. Balance around a joint is essential in any exercise program with a balanced ratio of agonist and antagonist training(21). Coordinated patterns of training are covered in functional training. Plyometric exercises are also useful in developing muscle power .They use a stretchshortening cycle to elicit a more forceful concentric contraction. Associated with rapidly

changing eccentric to concentric action, it has been suggested that they may develop reciprocal reflex training which may be useful in injury prevention. It is used 2-3 times per week but discontinued if the athlete develops pain, swelling or other signs of overuse. It has also been employed as a strengthening technique in uninjured athletes.

21 Basmajian Therapeutic Exercise 4th Ed Williams and Wilkins 1984 22. RM Poole Therapeutic Exercises for the Injured Athlete 1994 Appendix VII p599 in Sports medicine for the Primary Care Physician 2nd Ed RB Birrer Ed CRC Florida 23 Schram D Resistance Exercise Therapeutic Exercise Mc Master University 1980

Flexibility Flexibility exercises have two benefits. First in allowing and encouraging joint ROM exercises, they are a factor in return of normal joint mechanics. Second the effect of graduated stretching over time increases the length of contractile units and connective tissue elements within the muscle. As the muscle, tendon and enthesis are part of the same contractile unit this helps reduce injury. Blood supply to the tendon is predominately from the muscle with less from the bone attachment/enthesis. There is a critical area in the tendon which is susceptible to injury and ischaemia(24). Flexibility exercises have the effect of improving the efficient range of muscle contraction and preventing avulsion at tendon bone junction by reducing the chance of end range ‘bow stringing’. After injury stretching after physical therapy such as ice or heat reduces the activity of the fusimotor system, provides analgesia and often allows a greater ROM(25). Stretching regimes are from 30~60 seconds; times 3 repetitions; twice daily. Ballistic (bouncing) exercises or passive stretches by weights machines or trainer, run the risk of muscle tears. A slow stretch and creep technique is preferred, progressive to the limit of discomfort and NOT beyond. The desired muscle length may require twice daily stretching for six weeks with maintenance once daily. Specific stretching exercise programs are available in many forms. A basic lower limb stretching is provided(Fig 15). Proprioceptive Neuromuscular Facilitation Stretching (PNF) reduces muscle tone by stimulating the Golgi tendon organs. It relies on synergies using agonists activities to relax antagonists. PNF involves Proprioceptive and tactile techniques to cause muscle relaxation and repetitive activities to establish patterns of muscle contraction(17). Various movement and flexibility paradigms are prompted by diverse groups. These include yoga, Bowen and Alexander techniques and Feldenkrais. The authors believe that each has its merits although blindly following the teachings of self promoting ‘gurus’ is unscientific.

24 Takami et al Traumatic rupture of the extensor tendons at the musculo-tendinous junction J. Hand. Surg. Am. May 1995 20(3) : 474-7 25 Ganong Review of Medical Physiology 17th Ed 1995 Appleton and Lange

Endurance Endurance refers to the ability of a muscle to perform a static (isometric) or dynamic (isotonic) task. It depends on the state of the individual muscle and the cardiovascular status of the individual. A guide to endurance can be made by using physical work capacity measures, or pulse verses workload. A linear relationship exists between oxygen uptake and pulse rate. Using the Astrand nomogram a predicted VO2 maximum may be determined (26).Other protocols have been used in cardiovascular testing. An example is the step test whereby the number of steps of a given height from the floor, up to a bench, taken in a given period is recorded. As a minimum cardiovascular and endurance training should occur 20 minutes, 3 times weekly . Most athletes will easily exceed these guidelines. For an in depth description of cardiovascular fitness and aerobic exercise readers are referred to exercise physiology texts. The benefits include cardiovascular training, metabolic stimulation, maintenance of muscle bulk release of endocrine hormones and immunological modulation. There is evidence that endurance training of unaffected body parts has trophic effects on the injured area. It also may have positive psychological effects in individuals (27). Many methods are available to provide aerobic and endurance training for the injured athlete. They include: •

Swimming

•

Water exercises(hydrotherapy)

•

Brisk walking

•

Circuit training

•

Calisthenics/ Aerobics

•

Stationary bicycles

•

Machines (stepper, rowing, arm crank etc)

Swimming is the preferred exercise in most cases as the activity is non weight bearing and is less prone to re injury. The particular regime will depend on the site, nature and age of injury and on the individuals circumstances and skills.

26 Astrand and Rodahl, Textbook of Work Physiology Physiological Basis of Exercise Mcgraw Hill 1986 27 Dickinson and Benett Therapeutic Exercise Clinics in Sports medicine 4/3 July 1985

Proprioceptive retraining

Ligaments and to some extent tendon injuries are accompanied by an impairment of proprioception which may persist after the inflammatory phase of the injury is resolved (28). The three cues to balance are vision, vestibular function and lower limb position sense proprioception. Following an injury, position sense of a body part in relation to space or other objects is often diminished or lost. The goal of proprioceptive exercises is to reduce the time between neural stimuli and muscular response, thus reducing the stress on the injured joint during functional activities. Rehabilitation of injuries to the knee and ankle require proprioceptive retraining. Whiplash injuries cause abnormal neck proprioception and upper limb injuries may also require retraining. The components of lower limb proprioceptive training include: •

Taping or external supports to provide increased sensory input and protection during the early phases.

•

Static balance exercises standing on one leg initially then graduating to less firm surfaces e.g. foam and eventually wobble board.

•

Reduction of visual cues using blindfold or distracting activities during balance exercises e.g. throwing a ball to and from trainer or against a wall and catching.

•

Dynamic training such as jogging in soft sand progressing to figure of eight or zig zag patterns. During the later stages of recovery jogging on firm surfaces then finally uneven surfaces

28 Leanderson et al Proprioception in classical ballet dancers A prospective study of an ankle sprain on proprioception in the ankle joint Am J Sports Med 1996 May-June 24(3) 370-4

Functional training Functional training begins as the healing process allows. It is composed of the components already mentioned. Strength, flexibility, propioception and endurance are required (11). Muscle groups are exercised in tandem allowing coordinated purposeful movement. Specific weakness patterns and technique errors can be addressed. This then has benefits on strength and endurance allowing further functional training. These exercises may begin with partial squats, leg presses, step-ups, lunges, or closed-chain terminal knee extension. As symptoms subside and function improves devises such as reciprocal (vertical or stair) climbers, lateral slide boards, treadmills are used. A progressive walk-jog-run program can begin as healing proceeds. For Example, a basketball player with a knee injury could perform a compound exercise such as a set of body weight squats, when pain free. This could progress with increased weights

and gradual introduction of standing jumping exercises. This could be enhanced with a plyometric program of exercises. Functional Training can be general or sports specific. It can be supervised by trainers, therapists, coaches or parents. Athletes enjoy it and it is part of a graduated return to full activity. It is useful for acute and chronic injuries. It has been shown to decrease time off employment and speed return to sport(29).

29 Karlsson et al Early functional treatment for acute ligament injuries of the ankle joint Scand J Med Sci Sports 1996 Dec6(6) 241-5

Psychological The athlete with an injury requires consideration, understanding and empathy. They may be suffering not only an injury but financial and emotional stress. Body image is very important to athletes as well as the endorphin drive they have to exercise. Research suggests that athletes respond to injury with mood disturbance and lowered self-esteem(30). Calm explanation of the diagnosis, education and involvement in the rehabilitation plan are important parts of the therapeutic relationship(31). More time is often required than with other patients but the usual excellent results offer the clinician satisfaction. The recruitment of the athlete to taking an active role in their rehabilitation will facilitate the process. In extreme cases a reactive depression or post traumatic stress may intervene(30). These may be treated by supportive psychotherapy and appropriate medication. Following physical recovery confidence and athletic performance may be slower to return. Education ,explanation and support are required. A Sports Psychologist may help.

30 Smith Scott and Wiese The psychological effects of sports injuries coping Sports Med 1990 Jun9(6) 352-69 31 Smith et al Emotional responses of athletes to injury Mayo Clin Proc 1990 Jan 65(1)38-50

Biomechanical factors Understanding the mechanism of the injury will help modify the activity to prevent reinjury. If this is not corrected adaptive protective behavior may lead to a second and apparently unrelated injury. Biomechanical factors can be assessed by attending the events and being involved as team doctor. A detailed history and examination of the athlete is essential. Some sports have inherent physical demands which cause particular injuries e.g. female gymnastics forces girls to hyper-extend their backs and weight bear on the upper limbs leading to injury rates approaching 30% per year!(31).

Some injuries are caused by combinations of athletic activity, technique and individual anatomy. Plantar fascitis in which biomechanical factors are crucial in the prevention ,treatment and rehabilitation is a good example(33). Subtle abnormalities at a high level of skill may only be diagnosed by video, gait and force plate analysis. A coach may help in these areas for technique advice. Foot wear modifications may be the logical starting point for runners. e.g. ilio tibial band friction syndrome may be improved by reducing tibial rotation by insertion of an anti-pronation shoe or orthoses (34).

32 Lindner and Caine ‘injury patterns of Female Competitive Club Gymnasts’ Can J Sport Sci. 1990 Dec; 15(4) : 254-61 33 Chandler and Kibler A biomechanical approach to prevention, treatment and rehabilitation of plantar fasciitis Sports Med 1993 May 15(5) 344-52 34 Rose G Orthotics Principles and Practice William Heineman 1986

Return to sport (Table2) When the components of the rehabilitation process have been applied correctly the synergist nature of the treatment should enable return to sport. After a subjective assessment from the therapist or trainer that the athlete is able to use the injured extremity well. The athlete's ability to demonstrate enough self-confidence to fully participate in these activities without experiencing pain, swelling or giving way is assessed. The athlete progresses to sports-specific activities in a noncompetitive environment. Their performance should be critically evaluated by the rehabilitation team. Specific stress testing may be performed. Rehabilitation of four common injuries. Tennis elbow Tennis elbow is an enthopathy. It is also known as lateral epicondylitis Inflammation occurs at the common extensor origin of the wrist and finger extensor muscles on the lateral humeral epicondyle. On the first presentation Rest , Ice, Compression, Elevation and optional drug analgesia is provided. Within 24 hours the program is begun. Stretching the extensor and opposing flexor groups of muscle is taught. This is followed by a graduated weight training for forearm and wrist consisting of sets of 20 repetitions with weights ranging from 100gm to 500gm for each

movement of the wrist, that is flexion, extension, pronation, supernation and radio-ulnar movement. This regime is aimed at improving strength and endurance in the muscles and increasing the range of movement in the joints. The regime is repeated 4 times daily with ice applied over the lateral epicondyle for anti inflammatory and pain relief at the end of each session(35). Passive treatment such as ultrasound, indifferentual and gentle massage may help. Antiinflammatory drugs are sometimes employed. Bio-mechanics may be altered by a change in wrist action during backhand and increasing the size of the racket grip by wrapping with layers of tape and foam. Maintaining range of motion in the shoulder and cardiovascular fitness can be achieved by swimming sessions (crawl or backstroke) 30 min 2-3 times weekly. Active participation in running, cycling or other aerobic activities is encouraged. Psychological issues can usually be resolved by explanation, education and providing support. Rehabilitation of this injury may take 6-8 weeks(35).

35 Wilson Assessment and rehabilitation of repetitive strain injury in a clinical setting J Occup health Safety 1985 (2)126-9

Sprained ankle The most common ankle injury is an anterior talo-fibular ligament strain on the lateral side. More sever injuries cause damage to the calcaneal-fibular ligament with the possibility of medial deltoid ligament injury as the ankle is forced through more extreme inversion. After the immediate period of PRICE see table 1, diagnosis and exclusion of fracture occur. Appropriate antiinflammatory and analgesic measures are taken and a rehabilitation plan implemented. Initial treatment days 2-5 focuses on protection with reduced weight bearing, oedema management and analgesia. Passive physical treatment is used together with medication and gentle active range of motion exercises. Simultaneously cardiovascular and endurance training using the unaffected limbs commences. Weight bearing proprioceptive retraining is required commencing 5-7 days post injury. The program involves twice daily sessions of standing on one leg at a time for periods from 1 to 5 minutes. Once standing has been achieved, then distraction of visual cues to balance such

as standing on one leg and throwing a ball against the wall, bouncing and catching drills are used. This can be progressed with the athlete standing on a wobble board. These sessions increase to twenty minutes twice daily. At the same time that static proprioception is being achieved, dynamic proprioception will be promoted by jogging in sand. Progressing to figure of eight running , jog run, sprint cycles and rapid changes of direction on a variety of soft, hard and uneven surfaces(36). The proprioceptive retraining can be facilitated by ankle strapping or bracing which provides increased sensory feedback and some protection from over inversion movements. The total treatment time varies by individual and sport but most injuries take from 2-4 weeks to functional return. Karlson et al report excellent results from early aggressive proprioceptive and functional retraining with mean return to sport in treatment group of less than 10 days(29).

36 Seto and Brewster Treatment approaches following foot and ankle injury Clin Sport Med 1994 Oct 13(4) 695718

Hamstring The hamstring muscles run from the pelvis and posterior femur to the tibia and fibular head. They contract concentrically to extend the hip, flex the knee and contract eccentrically for pelvic stabilization and during the gait cycle. Because of their long length and crossing of two joints (hip and knee) they are susceptible to muscle and connective tissue tears and recurrent injury(38)..Strains often occur during periods of acceleration. Prevention by pre warming stretches and warm ups is encouraged. After the initial period of PRICE (see table 1) and diagnosis a rehabilitation plan is formulated. Local passive treatment such as ultrasound and massage is commences with the therapist. Anti-inflammatories may be prescribed. Isometric exercise can begin within 24 hours. A graduated stretching program is begun(39). Stretching of hamstrings using stretch and creep technique for 30 -60 seconds times 5 repetition times twice daily with quadriceps and tendo achilles stretches essential. Simultaneously progressive resisted exercise (PRE), is prescribed based on a 10 repetition set repeated 2-3 times performed daily. Resistance is progressively increased as pain allows. Icing is combined with the stretching and exercise program. Balance must be achieved around the knee at a ratio of 60 quadricepts/40 hamstrings.

Therefore PRE is used to maintain quadriceps and calf muscle condition. Isokinetic exercise if available may speed muscle strength return. Biomechanical factors such as pelvic alignment, leg length and gait patterns may need review. Aerobic exercise to maintain endurance and cardiovascular fitness is integral. Swimming or other injury protecting forms are used. As recovery proceeds functional exercises such as squats, jogging, running and sprinting are reintroduced into the program. Caution is required as hamstringing injuries seem prone to recurrence.

37 Worrel Factors associated with hamstring injuries. An approach to treatment and preventative measures Sports Med 1994 17(5) 338-45 38 Upton et al Thermal pants may reduce the risk of recurrent hamstring injuries in rugby players Br J Sports Med 1996 Mar 30(1) 57-60 38 Taylor et al The effects of therapeutic application of heat or cold followed by static stretch on hamstring muscle length J Orthop Sports Phys Ther 1995 May 21(5) 283-6

Stress fractures These are overuse injuries typically in the lower limb of endurance athletes. They are caused by repetitive cyclical loading of bone which exceeds its repair capability(40). They occur most commonly in the tibia, malleoli and metatarsals (March fractures)but have been reported at other sites.. They cause pain and disability. If training continues stress fractures can progress to complete fractures. There is considerable variation in susceptibility to such overtraining injuries. Diagnosis is confirmed by x-ray, bone scan, CT or MRI alone or in combination. The principle treatments are rest, maintenance of cardiovascular fitness and correction of underlying biomechanical factor. Endurance/cardiovascular fitness is maintained by non weight bearing exercise e.g. swimming, water exercises, circuit classes and machines. Rest is required. If compliance is poor use a POP to immobilize the limb. Walking for usual daily tasks is not detrimental. Some fractures e.g. navicular require strict NWB(41).Others e.g. anterior tibial epiphyseal stress fractures may require surgery. Education, counselling and support are the keys to treatment of stress fractures. The psychological concerns of these athletes must be addressed. Problems focused, behaviourally based regimes to reduce uncertainty are recommended(30).The athlete must be alerted to the tissue limitations from training. Over

training has detrimental effects on the immune system and endurance with poorer performance and high injury rates. Confidence of the athlete and compliance with treatment will be more likely if the sports physician is specific about periods of complete rest and a guaranteed return to training with a rehabilitation training schedule.

40 Reeder et al Stress fractures Current concepts of diagnosis and treatment Sports Med 1996 Sept 22(3) 198212 41 Khan-KM Brukner PD Kearney C Fuller PJ Bradshaw CJ Kiss ZS Tarsal navicular stress fracture in athletes

Complications of rehabilitation The commonest problem is reinjury occurring due to return to sport before injury recovery is complete. This may be due to the athlete, inadequate rehabilitation or external pressure such as coaches. Other injuries may occur due to athletes trying to protect their original injuries and subsequent altered behaviour or biomechanics. Injury may occur in another area from trying to protect the primary injury. Over aggressive rehab may be detrimental. Myositis ossificans occurs in some young athletes following a blow to the thigh and subsequent quadriceps haematoma. Haematomas are common injuries in the contact sports. Overzealous stretching, strengthening and massage can provoke a further haemorrhage which promote fibroblasts to differentiate into osteoblasts and for formation of bone within the haematoma. This can lead to pain, decreased range of knee motion and residual disability. Drug treatment always carries significant risk of side effects. Passive physical treatment can cause injury if incorrectly applied. Failure of rehab may precipitate psychological and emotional distress. Prevention The prevention of injury is important. The duty to the patient is greater than the team or sporting event. If injury occurs assess prior to continuing. If health is in danger, discontinue the activity. General principles: •

Adequate training and preparation prior to competition(weeks/months)

•

Consider body physiognomy, maturity and experience to compete. ‘Profiling’ is a concept that matches an individuals physiognomy with the type of sport and in team sports to their role.

•

Sports facility factors. Such as state of competition area, equipment maintenance, injury treatment equipment and air pollution.

•

Rules and aims of sporting contest

Individual Factors: •

Treat illness or injury

•

Some athletes should be prevent from high risk sports (e.g. epileptics should not scuba dive)

•

Maintain equipment

•

Adequate warm-up(stretching, cardiovascular and psychological preparation)

•

Protective equipment used

Table 1 Protection

is to prevent further injury and may involve the use

Rest

of tape, padding or external supports is relative; the injured body part is ‘rested’ while the unaffected parts are exercised. Rest should not

 

mean inactivity.   20 minutes every 2-4 hours while the patient is

Ice Compress Elevate

awake for first 48-72 hours Bandage, tape or brace for majority of acute period affected limb for 1-2 hour periods during the day a pillow under an injured limb at night

Table 2 Guidelines for return to sport after injury

 

•

acute signs and symptoms have passed

•

full functional use of all joints, adequate strength and proprioception to perform tasks

•

normal mechanics of movement

•

successful performance of sport specific activities at or above pre-injury level should be documented