A team approach consisting of the physician, therapist, athletic trainer, coaching staff, and the athlete is essential in the comprehensive rehabilitation of the athlete.

Communication with the sports medicine team along with an accurate and differential diagnosis is the beginning of a successful rehabilitation process.

Communication between the rehabilitation specialist and physician should concern the type of injury, surgical procedure performed, method of surgical fixation, results of any diagnostic tests, integrity and quality of the patient’s tissue, and physician’s patient-specific expectations, so the appropriate rehabilitation program can be designed and implemented.

The rehabilitation specialist must determine specific functional impairments and specific structures involved by a thorough and systematic examination.

The rehabilitation program must be designed based on the patient’s unique response to injury and the athlete’s specific functional needs.

Program phases are designed to emphasize goals that are specific to the appropriate time frame of tissue healing at that particular point in rehabilitation:

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  Each phase will have specific goals that must be met, such as full range of motion (ROM), before progressing to the next phase.

  
  
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  Patients will reach milestones at different times, so criteria-based progression should be promoted over time-based progression.

  
  
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  Criteria-based progression assists with locating areas wherein the patient may be gradually improving and may thus need to be more heavily emphasized.

Establishing a differential diagnosis based on involved structures and causes contributing to the lesion is a fundamental part in designing the rehabilitation program.

Clinicians must promote healing while being careful to not overstress healing tissues.

The program must be progressive and sequential with each phase building on the prior one.

Advancing a patient too quickly can result in inflammation, soreness, and potentially, tissue failure as opposed to controlled application of specific stresses, which can benefit healing tissues.

The first goal in many rehabilitation programs is to decrease pain and effusion.

Swelling stimulates sensory nerves and leads to an increase in the athlete’s pain perception.

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  Pain and inflammation can work as muscle inhibitors, thus causing disuse atrophy the longer the effusion is present.

Treatment options for swelling reduction include elevation, cryotherapy, high-voltage electrical stimulation, and joint compression.

Patients with chronic joint effusion may benefit from using a knee sleeve or compression wrap to apply constant pressure while they perform everyday activities; such devices can minimize joint effusion.

Patients with acute inflammation benefit from ice and elevation.

Pain may play a role in muscle activity inhibition that is observed with joint effusion.

Pain can be passively reduced through the use of cryotherapy and analgesic medications.

Commercial cold wraps immediately after surgery can be extremely beneficial.

Passive ROM (PROM) may also provide neuromodulation of pain during acute or exacerbated conditions.

Therapeutic modalities such as ultrasound and electrical stimulation may be used to control pain via the gate control theory of pain.

The speed of progression of rehabilitation, particularly weight-bearing and ROM, may affect pain and swelling; thus, any increase in pain and effusion in the involved joint should be monitored as the patient progresses and adds additional exercises ( Fig. 43.1 ).

Range of motion.

New exercises should be carefully monitored to ensure the pace of rehabilitation is appropriate and the tissue is not being overstressed; this is particularly important with procedures involving articular cartilages.

Persistent pain, inflammation, and swelling may result in long-term complications involving ROM, voluntary quadriceps control, and a delay in the rehabilitation process; thus, it is imperative that these symptoms be minimized.

An evidence-based rehabilitation approach should be utilized to best direct clinical care, which allows for a more predicable functional outcome.

When progressing a patient through rehabilitation, consideration must be given to the healing tissue itself.

Consider if the patient is ahead of schedule and has no complaints: Can the patient continue at an accelerated rate without compromising the long-term health of his/her tissue?

Another consideration: Does someone returning at 4 months have better outcomes than someone returning at 6 months?

Several characteristics must be considered when deciding the speed of rehabilitation:

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  The patient’s age, genetics, nutrition, concomitant injuries, and unique healing characteristics can all affect the rehabilitation timeline.

  
  
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  Injuries to the meniscus and or collateral ligaments can slow the rehabilitation process, for instance, following anterior cruciate ligament (ACL) surgery.

  
  
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  Clinicians must also be aware of nonvisible concomitant injuries, such as bone bruises, that are associated with ACL injuries.

Critical decisions have significant effects on metabolic activity of the injury site and the return to normal joint homeostasis.

The risks and consequences of accelerated rehabilitation must be evaluated for each patient.

The science of rehabilitation should be applied to all injuries and surgeries, particularly rotator cuff repairs, superior labral anterior posterior (SLAP) repairs, meniscus repairs, and related procedures.

Restriction of motion is often necessary in acute stages to promote tissue healing. ROM restriction can cause (see Fig. 43.1 ):

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  Quick loss of muscular girth and strength

  
  
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  Joint contracture

  
  
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  Loss of proteoglycan and weakening of articular cartilage

“Motion is lotion for the joint.”

Deleterious effects of immobilization must be minimized and immobilization should be avoided in almost all cases.

Current research indicates immediate controlled motion is critical to a successful outcome.

PROM is often performed by a skilled clinician but can also be applied in the form of continuous passive motion (CPM).

PROM can also be applied by an isokinetic device set in a PROM setting.

CPM following surgery has several benefits, including avoidance of arthrofibrosis.

Rehabilitation must also focus on retardation of muscular atrophy and facilitation of volitional muscle activity following injury or surgical procedure.

Effusion can decrease voluntary control of surrounding musculature; this can affect the patient’s ability to control his/her limbs and ambulate with a normal gait pattern.

Exercises designed to enhance muscular volition begin with basic isometric contractions.

Isometrics ( Fig. 43.2 ):

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  Allow firing of the muscle fibers without joint motion

  
  
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  Are a safe and effective method of exercise during early rehabilitation

  
  
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  Are most often used at multiple static angles throughout the available ROM

  
  
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  Have been shown to be one of the most efficient forms of exercise to increase muscular tension and improve strength

Isometric exercise.

Muscle re-education with electrical muscle stimulation (EMS) may assist in restoring the patient’s voluntary control of inhibited musculature.

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  EMS is often concomitantly used during isometric and isotonic exercises to increase recruitment of muscle fibers during contraction.

  
  
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  Several recent studies have found that patients that add neuromuscular electrical stimulation (NMES) to postoperative exercises have stronger quadriceps and a more normal gait pattern than nonusers.

  
  
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  Biofeedback can also be used to enhance voluntary control of injured musculature.

  
  
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  Clinically, NMES is used following injury or surgery while the patient performs isometric and isotonic extremity exercises.

  
  
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  NMES is typically used before biofeedback when the patient presents acutely with the inability to activate the musculature.

  
  
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  Once independent muscle activation is present, NMES may still be used to recruit additional motor units, thus resulting in greater strength gains.

  
  
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  NMES is typically used 4–8 weeks after ACL surgery or following selected shoulder surgeries.

  
  
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  Biofeedback is used for patellofemoral patients when they are unable to actively recruit their vastus medialis; the biofeedback causes the patient to concentrate on neuromuscular control.

Dynamic stability refers to the patient’s ability to stabilize a joint during functional activities to avoid injury.

Dynamic stability involves neuromuscular control and the efferent (motor) output to afferent (sensory) stimulation from the mechanoreceptors.

Proximal stability should be established to allow for distal segmental mobility to occur within the kinetic chain.

Dynamic stability of the glenohumeral joint is primarily achieved through interaction of rotator cuff muscles as they blend into the joint capsule.

Contraction of the rotator cuff produces tension within the joint capsule, which centers the humeral head on the glenoid.

Muscle weakness or strength imbalances of the posterior cuff muscles may have deleterious effects on shoulder mechanics.

Emphasis should be placed on linking the upper extremity with the lower extremity. Exercises should link the scapula with the hip, hip with the knee, hip with patellofemoral joint, scapula with the glenohumeral joint, and the scapula with the elbow.

Exercises to enhance dynamic stability are emphasized immediately following injury or surgery through the use of rhythmic stabilization drills.

Alternating isometric contractions are performed to facilitate co-contractions of the anterior and posterior rotator cuff.

Drills are progressed to include stabilization at end ROM and with the patient’s eyes closed, particularly for overhead-throwing athletes, in whom dynamic stability is compromised during the throwing motion.

Early proprioception and kinesthesia exercises are important for patients returning to sports because researchers have shown a decrease in these abilities following injury.

Basic exercises designed to enhance the athlete’s ability to detect the joint position and movement in space are performed to establish a baseline of motor learning for additional neuromuscular control exercises that will be integrated at a later time.