Critical question 4: How is injury rehabilitation managed?
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.
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)
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 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.
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.