The Final Stage of Rehab—Getting All the Way Back


the final stage of rehab

getting all the way back





Editor’s Note: The first parts of rehabilitation are relatively easy with respect to every athlete’s psyche. You follow the right protocol, strength returns appropriately, scar is minimized, and the pain goes mostly away. Psychology comes into action in this final part of rehab—the stage of getting the player, or even the construction worker, all the way back to his/her sport or other activity. This is when the pressure begins. Expectations and the real timeline for return for participation begin to overlap. Pressure grows on everybody (eg, player, management, fans, agents, and doctors). Conflicting goals abruptly cloud the picture. Nonmedical factors enter into the scenario—contract status, team security, disability payments; the list is long. A number of years ago, during spring training, a star MLB centerfielder going into his free agency year gets hurt and has surgery for a simple rectus abdominis tear. The return-to-play time was predicted to be only 3 weeks. The player might have to do a minor league “rehab stint” after that, before rejoining the “big show” team. At the same time, an important person within the team management hierarchy decides he wants to see how well a promising minor league centerfielder might perform during this star’s absence. The thinking is this: If the promising centerfielder plays well, then contract negotiations with the veteran star centerfielder’s agent might go better. The team’s management person tells the owner it might be “3 months” rather than 3 weeks before the star would return. Of course, it becomes difficult for that management person’s agenda to stay private. The player finds out and gets upset. Things start to play out in the press.

This case exhibits the complexity of return to play. The contemplations go way beyond the medical aspects of the patient/player. They enter the world of psychology, politics, and sometimes into a spooky expanse—what Rod Serling used to call “The Twilight Zone.”

I asked Andrew Small, an excellent young Australian sports physical therapist, to comment on this final stage of rehab.

The greatest accomplishment is not in never falling, but in rising again after you fall.

—Vince Lombardi, legendary NFL football coach.

I will never forget standing in the Great Court at the University of Queensland, speaking to my former mentor. Humble and always willing to talk though my issues, he threw me through for a loop this time.

“I want to study physical therapy and work with athletes.”

I fully expected him to support this. He was my wisest advisor and strongest advocate, plus an internationally respected coach, researcher, and educator with over 30 years of experience working with elite athletes, including 12 Olympians. His words stunned me.

“Are you sure you want to do this?”

He went on, “It may seem glamorous traveling around the world, working with these stars. But there are so many, let’s say, challenges. It’s not glamorous. They want results way beyond realistic expectations.”

I think, but am still not sure, that he was just testing me. As we talked more, he became convinced of my passion. He said athletes want results “yesterday” and that the return-to-sport phase was the trickiest part of the physio’s job. “There are so many conflicts of interest that keep you from doing the job the way you want.” Having let off his steam, he finally succumbed and congratulated me on my chosen career.

Since then, I have learned that the return-to-play part of rehab is actually the most rewarding. It remains tremendously gratifying to see an athlete overcome injury and return stronger and actually better than ever before. That’s our aim in rehab of core injuries. We think that most athletes do not get the core training they should, and when they do after surgery, they often beat their previous personal bests.


Okay, let me tell you about a specific case, a diver before the Olympics (Figure 33-1). Just 4 weeks prior to the big qualifying event, this athlete suffered a mid-muscle belly rectus abdominis strain. He couldn’t dive at all. The medical team and I had just 7 days to wean the athlete back to full competition loads following 3 weeks off.


Figure 33-1.

We immediately implemented corrective and strengthening exercises to improve the capacity of both involved and uninvolved structures. With the qualifiers only 4 weeks away, we had 3 things to accomplish: (1) allow injured tissue to heal, (2) continue to improve his overall physical condition, and (3) preserve his technical abilities. The immediacy of a situation sometimes necessitates extraordinary treatment. The old concept of rest simply does not usually apply to core muscle injury.

Don’t get me wrong, we did some degree of modified rest. We used the combination of pain and performance as our guide, graded by some specific functional tests. Exercises were designed to protect as well as improve the capacity of that one specific area to load. He was allowed to work through some pain. Ranges of motion of the hips and lumbar spine and hip were maintained. We stepped up massage and other manual therapy, and monitored strength with a diving-specific 5-stage test. Our diver reentered the pool after he completed the test without symptoms. He had just 1 week left before competition.

The coaches kept in close contact, and technical training was planned jointly. The extra-swift training began with both dry land and pool sessions with modifications to reduce stress on injured tissue. We used how the symptoms reacted to the different types of sessions as measures of tolerance of the injured tissue to specific loads. The loads grew each day until our technical and physical goals of the demands of training reached the demands of competition. The coaches kept in close contact, and they planned the technical training.

We began with modified 1-m and 5-m drills. Then, fortunately, the day before competition, the athlete had earned the right to compete his full list from 10 m. The athlete competed successfully the next day and made the Olympic team and surpassed all expectations in the Olympics.

The diver shows that sometimes we physical therapists, athletic trainers, and other fitness people need to break from what we usually do. This is how I learned about these injuries. I developed a totally different attitude about return to play and changed all my protocols. Sometimes, we just have to cast away our old eyes and put on new specs.

A star on a movie set is like a time bomb.

That bomb has got to be defused so people can approach it without fear.

—Jack Nicholson, the famous Hollywood actor.


A recent author referred to the area we in this book are calling the core as “the Bermuda Triangle of sports medicine.”1 That has been the prevailing thought. Defuse that bomb. Many specific injuries occur there. Learn what they are and how to identify them and then treat them appropriately. We certainly don’t know everything yet about the core, but we know a lot, so at least know what we know. Don’t fear this area of the body any more.

From our rehabilitation point of view, therapists still get nonspecific referral notes from docs prescribing things as vague as a teenager’s description of what he/she did last night, scripts like “rehab for groin pain,” nothing specific, no directions. The plan then develops according to whims of the therapist and nonspecific, existing rehab protocols. The program then progresses to disagreements between the different rehab people, because the patient does not get better or reaches a plateau from which there is no escape. Arguments ensue regarding diagnosis and subsequent management.24 We therapists liken this situation to a ticking time bomb.

For estimating the best time for return to play, therapists generally have quantified loads and loosely used various monitoring devices. These approaches remain mostly guesswork.

Progress lies not in enhancing what is, but in advancing toward what will be.

—Khalil Gibran.


Over a 20-year period, technology and awareness of core muscle injuries have increased significantly.59 Paradigms1012 are evolving. The science has become much more straightforward, although no reliable formulas exist with regard to the precise timing for return to play. You still have to consider all kinds of factors. The best decisions demand a lot of experience. The factors include such things as precise identification of the injury, its severity and implications with respect to development of other injuries, many biomechanical considerations, current and necessary levels of strength, the playing season, and player contracts.

With a click of a button, we may come up with some technique. Beware, though, that the knowledge out there on the internet is usually wrong and often dangerous. On the other hand, we should embrace new technology, such as GPS accelerometers and cloud-based athlete management software.

As physical therapists, we also need to pay more attention to our performance and exercise colleagues. The 2 sets of professions actually complement each other. We need to adopt some of those traditional strength and conditioning principles. Recent research has demonstrated that the right amount of stress/load applied in a specific way can produce an adaptive cellular response in a number of tissues such as bone and tendon.1317

Old Lessons Applied in New Ways

The concept of load is as simple as it sounds. With human movement, various tissues are placed under load or stress. Whether it is compressive, like a knee joint, or tensile, like an Achilles tendon, many structures undergo stress during human movement. Too much load causes tissue failure and too little leads to weakness and an inability to tolerate stress.1822 Believe it or not, we shall never find the Holy Grail. Finding the exact “right load” is similar. Various concepts have nonetheless emerged as part of that righteous search such as mechano-therapy and mechano-transduction.23

Load monitoring has improved with the GPS and accelerometer technology. It allows us to compare objective loads to objective measures of tissue tolerance such as pain, swelling, tightness, and muscle tone. Patterns can be tracked and provide therapists with more information. We can make therapy decisions based on this.

Performance and strength coaches talk in terms of “specific adaptations to imposed demands,” or SAIDs. We as therapists must also understand those demands for specific tissues relative to the timelines for healing. If an athlete must run, we must figure out the tissue strength and what the muscles and bones need to withstand during running progression. The load and high-velocity movements shall be specific to the athlete and sport. Yes, we make a lot of judgments based on how the athlete feels. It is important to point out that we may easily correlate how the athlete feels to our objective parameters and make subsequent judgments based on multiple sets of data.

Streaming is the concept used extensively in sports performance education around the world.24 It involves categorizing movements into sequential linear progressions involving multiple muscle groups. One stream may involve a series of exercises to develop single leg strength, another to develop horizontal push. Be familiar with the term. Use it. It conveys the right principles of involvement of multiple muscles in a sequential way. We use it a lot in our return-to-play lingo.

For the core, we choose streams that develop hip adductor/abductor strength, abdominal endurance, single-leg strength, single-leg hop abilities, as well as running progressions. These streams can be customized depending on the various deficits observed after physical examination, the type and extent of injury, as well as the movement goals of the patient. A structured approach allows us to set a plan that ensures that an athlete earns the right to progress to higher loads.

History and Physical Examination Factors

History and physical examination remains the backbone of the treatment plan. We must consider all aspects of the core: the hip, back, core muscles, and all those important viscera and systems that reside there. On top of that, we as physical or other therapists should identify previous training errors and load difficulties. We palpate a lot and use the elicitation of pain (ie, tenderness) as one of our important guideposts. We must be ready to communicate our findings when they differ with the referring doctor.

We should palpate the pubic bone, adductor, and rectus abdominis insertions and all the muscles that attach to or pass by the pubic bone. Specific strength tests may provide additional information such as adductor squeeze (Figure 33-2)25,26 and pubic symphysis stress test (Figure 33-3).27 Some recent work suggests hand-held dynamometry may help assess hip muscle strength in at-risk populations.2832 There is no question that strength imbalances are risk factors for core injuries.32,33 Nobody yet is perfect with the use of these devices but they measure things objectively, which can be used as baselines for athletes who are injured or who just want to improve. We can devise our own protocols based on these data for return to play. We must recognize, however, that these are just tools. We really don’t know much.


Figure 33-2. Pectineus squeeze test.

Stay updated, free articles. Join our Telegram channel

Apr 2, 2020 | Posted by in SPORT MEDICINE | Comments Off on The Final Stage of Rehab—Getting All the Way Back

Full access? Get Clinical Tree

Get Clinical Tree app for offline access