Rehabilitation

Michael D. Jackson

“Doc, when do you think I will be ready to play again?” This is one of the most common questions asked of physicians practicing sports medicine. The top priority of injured athletes typically is the length of time it will take before they can return to competition. Highly motivated athletes often have tunnel vision after an injury. In some cases they are willing to risk reinjury (and perhaps even more serious injury) in order to return to their sport as soon as possible. Once the correct diagnosis is made, the team physician’s role is largely devoted to answering this basic question.

The primary intent of this chapter is to arm primary care physicians, who may be serving as team doctors for their community schools and/or caring for recreational athletes as part of their office practice, with the knowledge base necessary to answer questions regarding an athlete’s ability to return to competition.

The time it takes to safely return to competition is critical. Factors that influence the length of the recovery phase and ultimate return to activity include the specific injury, level of competition, age and sex of the athlete, and the ability to carefully monitor the rehabilitation process. When the “return to competition” question is asked, it is tempting to reply with a specific date. Typically, the situation is not that clear-cut. Therefore, the appropriate response is to outline a progressive, functional, rehabilitation (PFR) protocol and informing the athlete that when specific and objective functional goals are met, they can expect to safely return to competition. It is also imperative that before the injured athlete leaves the training room or your office, it is clear to them that most of the responsibility for reaching these objectives is on their shoulders. An injured athlete who stops by the training room infrequently, forgets to take medications, or neglects to follow the rehabilitation protocol, must understand the consequences. The recovery time is prolonged each time there is a variation from the prescribed plan of action.

Without a good understanding of the importance of the team approach to athletic injuries, it may be difficult for everyone involved in the care of the athlete to exercise common sense and good judgment. Consequently, deciding when an athlete is ready to resume play becomes even more complex. An injured athlete may attempt to get one member of the sports medicine staff to allow him/her to return to competition before it is safe, so it is paramount that everyone involved understands the concept of PFR.

Before discussing when an injured athlete is ready to return to play, one should be familiar with the principles of sports medicine rehabilitation (see Table 35.1). After these principles are covered, several rehabilitation protocols for common athletic injuries are outlined. Because 80% to 90% of these injuries are due to disruption of soft tissue structures, the primary focus of this chapter will be on restoring the integrity of soft tissues and preventing reinjury.

Principles of Rehabilitation

Prevention of Injuries

It has been said that “an ounce of prevention is worth of pound of cure,” and this is very appropriate with regard to athletic injuries. Injury prevention is extremely important to any team or individual. As team physicians, we attempt to minimize the overall impact that injuries may have during a season and one of the best ways to do so is to prevent them from occurring. Prevention is the fundamental axiom of sports medicine rehabilitation. All other guidelines stem from this primary concept. Table 35.2 gives the basic principles of injury prevention. A more thorough discussion is presented in Chapter 8.

Protection, Rest, Ice, Compression, Elevation

One of the most important concepts in managing acute athletic injuries is prompt intervention in order to mitigate the inflammatory response and resulting edema that follows soft-tissue trauma. The inflammatory response to
soft-tissue damage is a cascade of chemical, metabolic, and vascular events that lead to an increase in capillary permeability (1,2,3,4). Initially, these events serve a necessary and useful purpose in promoting soft-tissue healing. However, excessive swelling within or around a joint leads to pain, decreased range of motion (ROM), joint laxity, and diminished proprioception (5,6). Prompt, aggressive action to minimize the inflammatory response may reduce recovery time and permit an earlier safe return to activity. The first few hours of treatment often determine how quickly an injury will heal. The basic early treatments therefore focus on protecting the injured area, reducing the swelling, and decreasing the inflammatory process. Protection, Rest, Ice, Compression, and Elevationrotection, Rest, Ice, Compression, And Elevation (PRICE) make up the earliest methods of treatment in most cases.

TABLE 35.1 Principles of Rehabilitation of Soft-Tissue Sports Injuries

Prevention of injuries

PRICE

Early Mobilization and Restoration of ROM

Modalities

Medications

Restoration of balanced muscle strength and endurance

Maintaining cardiovascular fitness

Proprioception, balance, and agility

Flexibility

Protective taping and bracing

Psychological support

Functional progressive rehabilitation

PRICE = protection, rest, ice, compression, and elevation;
ROM = range of motion

TABLE 35.2 Principles of Injury Prevention

Preparticipation evaluations

Complete rehabilitation of previous injuries

Balanced muscle strength and flexibility

Proper body mechanics

In-season and off-season conditioning

Aerobic and anaerobic fitness

Proper nutrition and hydration

Avoidance of overtraining and burnout

Appropriate warm-ups and cool-downs

Safe and appropriate equipment

Safe and appropriate field and court conditions

Protective Equipment, Taping and Bracing

Proper coaching techniques

Understanding the rules of various sports

Community education

Sports medicine network

Understanding the ethical dilemmas in sports medicine

Protection may involve several strategies. Temporary immobilization with a cast, splint, or brace is sometimes indicated; crutches to prevent or assist weight bearing on an injured lower extremity or a sling to support the upper extremity are both examples of protection. Preventing further injury to a joint or extremity is paramount. Placing an athlete with a Grade I or Grade II ankle sprain on crutches for 3 to 5 days after injury may seem a bit extreme. However, depending upon how much walking the athlete must do, the condition of the walking surfaces, and the reliability of the athlete, this protective step may be warranted. If there are any concerns regarding the potential for further injury, always err on the side of caution and protect the injured joint or extremity as much as possible.

Rest is probably the most difficult thing to convince an athlete to address, but it is very important in the early course of an acute injury. In some situations, relative rest is indicated as opposed to absolute rest. Some key points must be made about the type and amount of rest needed. First, repeated microtrauma to an already injured tissue can cause further injury and prolong healing. However, immobilization can lead to soft-tissue contracture, loss of ROM, muscle atrophy, and deconditioning. There is a fine line between too much rest and too much activity in any rehabilitation protocol. You can be assured that you are on the correct side of the line so long as progression through functional stages continues in the absence of increased pain, progressive joint instability, and/or swelling.

Ice is possibly the single most important part of any sports medicine staff’s armamentarium. It is cheap, easy to use, readily available, and has few contraindications (7). Ice therapy causes vasoconstriction, decreasing edema and the metabolic demands of injured tissues. It decreases muscle spasticity and has a local analgesic effect. Ice helps limit the inflammatory response and thereby the extent of injury. The controversy over cold therapy versus heat therapy will be discussed later. The important thing to remember is that ice is the modality of choice for the initial treatment of acute soft-tissue injuries.

Compression is very useful in minimizing the extent of soft-tissue swelling (6,8). In fact, several authors believe that it is the single most effective deterrent (8,9). Again, the rationale is to control edema so as to reduce the recovery time. Figure 35.1(b–f) demonstrates how compression is used after an ankle injury. A foam pad is prewrapped to the lateral side of the ankle to prevent capillary leakage and enhance lymphatic drainage. A U-shaped foam pad (see Figure 35.1(b)) tailored to fit around the malleolus is probably most effective. Once the pad is applied, it is imperative to keep it in position. Ice packs can be placed on top of the pad but the pad itself should not be removed until the ecchymosis begins to turn yellowish. The change in
skin coloration represents the breakdown of hemoglobin, and rebound swelling is unlikely at this stage.

Figure 35.1 Ankle Taping. A: Materials needed: 1½ inch adhesive tape, prewrap, tape adherent spray, pressure padding. B: Spray ankle with adherent, and then apply pressure pad(s). C: Apply prewrap beginning distally at the head of the metatarsals and continuing proximally to midcalf, then apply distal and proximal tape anchors. D: Apply vertical stirrups beginning slightly posterior to the malleoli. E and F: Completed ankle taping should be tight enough for support and protection and loose enough to allow for swelling.

This technique is much more effective in controlling edema than using standard elastic wrapping. Elastic wraps can be counterproductive. If wrapped too tightly and left on for prolonged periods, they can have a tourniquet effect. Once the appropriate compression wrap is placed, regular monitoring is essential to assure that edema is not increasing. A pneumatic compression device may also be very helpful for controlling edema.

Elevation plays an obvious role in minimizing swelling, but it is often forgotten. Rather than telling an athlete to go home and soak his/her newly sprained ankle in a bucket of ice water, explain that it would be more effective to wrap an ice pack around the ankle and elevate it. This is particularly true within the first 24 hours, when keeping the injured extremity elevated higher than the heart is essential.

The PRICE protocol is aimed at minimizing the swelling that accompanies acute trauma. Taken individually, each step may seem insignificant, but the summation of these interventions can be dramatic (4,5,6,7,8,9,10,11).

Early Mobilization and Restoration of Range of Motion

Early mobilization after soft-tissue injuries, fractures, and surgery is a topic that warrants considerable attention. Not everyone supports this concept. There is considerable controversy regarding the nonoperative management of ankle sprains (6,11,12,13). As noted earlier, temporary immobilization may be indicated, depending upon the athlete and the circumstances. However, long-term immobilization should be avoided whenever possible.

There are several reasons to begin gentle ROM exercises soon after an injury. Early motion enhances lymphatic drainage and clearing of the necrotic debris, and also helps maintain joint proprioception and muscle strength (11,12,13). Significant increases in the strength and thickness of ligamentous tissue as a result of early motion and endurance exercises has been well documented (14,15,16,17,18,19,20). Finally, and probably most important, early mobilization minimizes joint stiffness and inhibits the development of soft-tissue contractures due to excessive scar formation. Collagen proliferation is part of the inflammatory response. Appropriate stressing of this new tissue promotes optimal organization of collagen fibrils and limits randomized scar tissue from impeding joint motion (21). Recovery time can be prolonged for several days or even weeks if an injured joint develops stiffness and a significant loss of ROM. Immobilization may be needed initially for protection, but some movement can usually begin shortly after injury. Always work within the pain-free ROM. Joint stability should always be monitored because an unstable joint should not be subjected to excessive ROM exercises. As rehabilitation advances, flexibility exercises can be escalated. However, if there is prolonged postexercise pain, the ROM exercise regimen should be reduced to previous pain-free levels.

Therapeutic Modalities

Detailed discussions about the technical application of different modalities are often neglected in clinical settings. Many physicians have little knowledge of the principles behind the various modalities and their application, partly because this work generally falls under the domain of athletic trainers and therapists. Even so, a fundamental understanding of each modality is important. Every time one of the modalities is used, a specific, objective goal should be kept in mind, including the timing and sequence of their use. The intensity, duration, and frequency of application can be critical in expediting recovery.

Finally, many treatment regimes become popular without adequate evidence of their efficacy. Comprehensive review of the literature highlights how little we actually know about the physiological principles and efficacy of many modalities.

Cryotherapy

Cold therapy is one of the most common therapeutic interventions applied after acute athletic injury. Cooling an injured joint or extremity has an analgesic effect as well as retards secondary injury (4,22,23). Cryotherapy is also believed to reduce acute edema by decreasing blood flow (24,25), metabolic activity (22,24), and permeability of postcapillary venules (26).

There are several ways to apply cold therapy, including ice massage, ice water immersion in a whirlpool bath, an ice blanket or pack, or immersion in ice water slush. Coolant sprays in the form of ethychloride or fluromethane are used for topical anesthesia and in the techniques of spray and stretch.

Ice massage means local application of an ice cup in a circular motion for a period of 5 to 10 minutes. Ice water immersion, either in a whirlpool or ice water slush, is good for treating a larger area of injury or one involving bony or irregular surfaces (e.g., lateral malleolus). After analgesia occurs, the athlete can begin gentle ROM exercises while the injured part is immersed. This therapy should usually last up to 20 minutes and can be repeated every 1.5 to 2 hours. Ice packs are applied in a similar manner. Remember that the application of any form of cryotherapy for extended periods of time may cause temporary or even permanent injury to nervous tissue (27,28). The therapeutic effects of cold therapy are listed in Table 35.3 and the contraindications are given in Table 35.4.

A common recommendation is that ice should be used for the first 24 to 48 hours after acute soft-tissue injury, followed by heat. We caution against using any set period of time. So long as there is evidence that swelling is increasing, do not start heat therapy. Edema can easily continue after the first 48 hours in an injured joint that is not treated
appropriately. Heat in this situation would potentially worsen the edema. Use ice until you are convinced the swelling has stopped. This may take several days, depending upon the type and extent of injury. Ice application after activity may also be indicated after an athlete begins PFR. Too often, the use of ice is neglected after the athletes are allowed to return to activity. When this happens, a small amount of edema may recur and prolong the recovery time.

TABLE 35.3 Therapeutic Effects of Cold

Vasoconstriction

Decreased muscle spasm

Increased threshold of pain

Relative anesthesia

TABLE 35.4 Contraindications to Cold Therapy

Raynaud’s phenomenon

Raynaud’s disease

Cold urticaria

Cryoglobulinemia

Paroxysmal hemoglobinuria

Cold presser response positive

Circulatory insufficiency

Anesthetic skin

Severe cardiopulmonary disease

Heat Therapy

The application of heat can bring about analgesia and a decrease in muscle spasms. However, if applied too soon, heat may actually increase pain by increasing edema. Therefore, heat should not be considered for initial treatment of an acute injury. The desirable therapeutic effects of heat include reducing pain, relieving muscle spasm, increasing blood flow, decreasing joint stiffness, and increasing the elasticity of collagen fibers (7,29). The effective therapeutic temperature is 40°C to 45.5°C (104°F–113.9°F), which is a very narrow range, and it is essential to remember that there is a thin margin between the therapeutic range and the tissue damage range, which begins at 46°C (114.8°F). Therapeutic effects are determined by the duration of heating, total area treated, tissue temperature, and the rate of temperature rise in the tissues. The most effective duration is 3 to 30 minutes, depending upon the modality of application. Heat can be applied by convection (moist air cabinet, hydrotherapy), conduction (hot packs, paraffin), radiation (infrared), or conversion (diathermy, ultrasound). It can be applied in either superficial or deep form. The most common modalities for superficial heat are whirlpool baths and hydroculator packs. The most common modality for deep heat is ultrasound.

Superficial heat produces its highest temperature at the body surface but penetrates only a few millimeters into the tissue (7,29). Because the penetration of heat is minimal, superficial heat often is chosen for reflex muscle relaxation and its sedative effect. Immersing the trunk and all four extremities in a Hubbard tank will induce a mild fever in most people. Consequently, the maximum water temperature should not exceed 38°C (100.4°F). Immersion of a single extremity can be done safely up to 41°C (105.8°F). Remember that heating increases the metabolic demand of tissues. If ischemia is a problem (ischemic ulcer), keep the temperature at 35°C to 37°C (95°F–98.6°F). Heat application by hydrotherapy should be done in 20- to 30-minute periods because longer immersion may cause local tissue damage.

Hydroculator packs contain dried silica gel capable of absorbing and retaining water and heat. They are usually heated to a temperature of 65.5°C to 76.6°C (150°F–170°F) and then wrapped in several towels before being placed on the athlete. This helps control the transfer of heat by conduction. Treatment periods usually are 20 to 30 minutes long.

Another form of superficial heat is paraffin wax baths. The wax mixture usually consists of four to eight parts paraffin mixed with one part mineral oil. The mixture is heated and maintained at 50.5°C to 56.6°C (125°F–134°F) and can be applied by dipping or continuous immersion. Total treatment time usually is 20 to 30 minutes. This is a very effective method of treating injured joints of the hands and feet.

Radiant heat from infrared lamps has limited application in sports medicine; they are used mostly for dermatological conditions.

Deep heating modalities include short wave, microwave, and ultrasound. Ultrasound is the one most often used to apply deep heat for sports injuries.

Short wave diathermy is the therapeutic application of an electric current with a very high frequency that is converted to heat within the tissues. The two techniques of application are the condenser method and induction coil applicators. Treatment usually lasts 20 to 30 minutes and the highest temperature is obtained in the deep subcutaneous tissues of superficial muscles. It does not penetrate into deep joint structures.

A disadvantage of short wave diathermy is that it cannot be accurately dosed nor can the amount of energy transferred to the patient be monitored. The only safeguard against excessive heating is the athlete’s perception of warmth and pain. In addition, the patient must be kept dry because perspiration, which contains electrolytes, can serve as an electrical conductor and cause burning of the skin (see Table 35.5).

Microwave diathermy is a deep heating modality using high frequency electromagnetic waves. As with short wave diathermy, there is no accurate way to monitor the dose. Because microwave applicators are small and cannot be used to treat very large areas, their effectiveness is limited at present.

Ultrasound is a form of acoustic energy produced by mechanical vibrations. Ultrasound waves are at frequencies that are inaudible to the human ear (above 2,000 cycles/second). To produce energy for therapeutic purposes, a machine requires a generator of high frequency current and an applicator sound head with a transducer that
receives electrical currents of sufficient frequency to cause it to vibrate and produce sound waves.

TABLE 35.5 Contraindications and Precautions in The Use of Shortwave or Microwave Diathermy

Use near cardiac pacemaker

Use over the eyes

Use over open wounds or moist dressings (risk of selective heating)

Use over areas of increased perspiration (risk of selective heating)

Use over epiphyseal growth plates in children

Use over an area of infection (risk of spread)

Use over subcutaneous fat deposits in obese persons (selective heating of subcutaneous fat)

Ultrasound energy is transmitted to the tissues by this applicator. The waves do not pass easily through air, so an air-free medium must be interposed between the applicator and the skin. Mineral oil or a gel is the usual coupling medium. Ultrasound has the deepest penetration of any deep heating modalities. It is the only one that can directly increase deep tissue (muscle and bone interfaces) temperature to a therapeutic level (7,29,30,31,32), reportedly increasing temperatures at depths up to 5 cm (20,33,34,35,36). Deep heat can increase the elastic properties of collagen tissue, making it useful in the treatment of soft-tissue contracture, muscle spasm, and thrombolysis (37,38,39,40,41,42,43,44,45,46,47). When ultrasound is used with a gentle stretching and strengthening program, ROM is often returned to stiff and contracted joints. In addition to its role as a thermal agent, it has also been used therapeutically for healing wounds (17,48,49), pain relief (50,51,52) and acceleration of fracture healing (1,53,54,55,56,57,58). Ultrasound can be more accurately dosed than short wave and microwave diathermy. The therapeutic range is 0.5 to 2 watts/cm² and usually is applied for a period of 4 to 8 minutes. It may cause a feeling of local warmth and tingling, but if pain occurs, too much energy is being used. Another advantage of ultrasound is that it can be used with whirlpool baths to deliver deep heat over irregular bony surfaces such as the lateral malleolus.

The therapeutic effects of heat are summarized in Table 35.6. Table 35.7 lists the contraindications to heat therapy.

Contrast Baths

Contrast therapy combines heat and cold modalities, typically alternating between immersion in warm and cold water. This technique, indicated in subacute and chronic conditions, is believed to produce a number of physiological effects, including increased tissue temperature and blood flow, blood flow changes in both the ipsilateral and contralateral extremities, hyperemia of the superficial blood vessels, decreased muscle spasm, reduced inflammation, and improved ROM.

TABLE 35.6 Therapeutic Effects of Heat

Increased blood flow

Increased visco elastic properties of collagen

Sedation

Analgesia

Muscle relaxation and decreased muscle spasm

Increased metabolic rate

Increases the suppurative process

Typically, the injured extremity is immersed for 10 minutes in hot water, 40.0°C to 43.3°C (104°F–110°F). The injured part is then placed in cold water between 10°C to 15.5°C (50°F–60°F) for 1 minute. The total treatment time of 30 minutes is an alternating process, with hot water immersion for 4 minutes followed by cold water immersion for 1 minute after the initial 10-minute period of heat. A second method calls for submerging the limb in an ice slush bath for 2 minutes and then in tepid water at 33.9°C to 37.7°C (93°F–98°F) for 30 seconds. The baths are alternated for 15 minutes, beginning and ending with cold immersion (53).

Electric Stimulation

Electrotherapy has become very popular in sports medicine (31,33,34,59,60). It is used to increase the strength of healing ligaments and tendons (60), prevent muscle atrophy (31), and control swelling and edema (33

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