Therapy Considerations for Getting Athletes to Return to Play

During the protective phase of treatment, therapy for hand and wrist injuries in athletes is similar to the plan of care provided to all patients. The nuances in the care provided to athletes become apparent during the transition to the postprotective phase of rehabilitation when the focus has shifted to return to play. Therapy following a sports injury should address the individual needs of the athletes in their everyday lives as well as the specificity of their training and sports-specific activities. The factors that influence return to play are discussed.

Key points

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The rehabilitation considerations of athletes depend on the nature of the injury, sport, and level of play.
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The use of protective orthoses is established by sports-specific regulations, level of play, and position played, and may ultimately be determined by sport officials on the day of competition.
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The rehabilitation plan of care should not only focus on rapid, safe return to sport but should include strategies to optimize overall performance and to prevent future injuries.
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A team approach engaging in close communication between the athlete, surgeon, therapist, coaches, and trainers optimizes recovery and safe return to competition.

Introduction

The primary role of occupational therapists (OTs) or physical therapists (PTs) in the rehabilitation of athletes that have sustained a wrist or hand injury is to restore function and optimize performance for safe return to play (RTP) as quickly as possible. This article uses therapists to represent both OTs and PTs. Ideally, therapists possess specialized training in hand and wrist conditions consistent with the Certified Hand Therapist (CHT) credential.

The access points to treatment following sports-related injury vary depending on age of the athlete, level of play, time of season, and nature of the injury. Therapists may be the initial point of entry into the health care system for injury, but this does vary by the credential in the practice location (registration or licensure), clinic setting, years of experience, and age of patient. ^, For this reason, therapists are trained to perform screening examinations to determine whether the nature of injury is suitable for therapy management alone or whether the athlete requires further medical or surgical examination and treatment. ^, For example, an athlete with radial-sided wrist pain with a history of a fall on an outstretched hand (FOOSH) may make an appointment in a therapy clinic and state that the wrist is sprained. Based on the velocity associated with the FOOSH, and the presenting symptoms, the therapist may determine that imaging is needed to rule out a wrist fracture or ligament injury and, therefore, a referral to a hand surgeon is indicated.

Rehabilitation education emphasizes movement analysis and treatment strategies to assist patients to optimize their performance for everyday life, work, and play. Promoting health and wellness is a key component in the plan of care for all patients, including athletes, to maximize the patient’s experience, outcome, and overall health. ^,

Athletes as patients or patients as athletes

It is frequently stated that rehabilitating injured athletes can be a challenge, especially if they are unrealistic or anxious to RTP. However, RTP depends on many factors, and few standards for clinical decision making have been established. Box 1 provides a list of the common factors that influence RTP. The managing hand surgeon is typically the primary decision maker in determining RTP; however, the physician usually works collaboratively with the other members of the team. Team members may include the family physician, team physician, therapist, trainer, coach, agent, parent, league officials, and the athlete. The coordination of medical resources for injury management, rehabilitation, and determination of RTP varies based on the athlete’s level of play: professional, collegiate, high school, and youth.

Box 1

Factors that influence return to play

Data from Refs.

General
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  All team members bound to ethical considerations within their professional standards.
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  Parents have a voice in all athletes less than 18 years of age.
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  If clear guidelines are not available regarding the use of protective gear, consult sports officials.
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  For K–12 (kindergarten to grade 12) athletes, consult National Collegiate Athletic Association (NCAA) guidelines, league rules, and state boards of education.
Nature of hand/wrist injury:
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  Traumatic injury may require complete healing to use the hand.
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  Traumatic injury may be sufficiently protected with an orthosis to allow use of hand.
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  Overuse injury may be sufficiently protected with an orthosis to allow use of hand.
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  Overuse injury may lead to more significant injury if not handled immediately.
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  Overuse injury may be sufficiently managed during season to delay further treatment to after the season.
Timing in the season:
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  Injury may be season ending because of the severity of the injury.
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  Minor injuries may be protected to delay care until end of season.
Level of play:
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  Elite (regulations, legal, contractual)
  - Professional athletes: legal or contractual factors associated with sports association/league
  - Collegiate: NCAA regulations; impact on scholarship or eligibility
  - High school: not regulated by NCAA; impact on scholarship or college recruitment; resources provided by AAOS, ACSM, NFHS, AAHPERD; generally accepted that full healing of injury should occur
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  Nonelite (less regulated; note from physician may be required to return to participation)
  - Leisure: not regulated at any age; athletes 18 years of age and older make independent decisions regarding their care; athletes less than 18 years of age must have parental permission
  - Intramural/club: not regulated by NCAA at collegiate level; K–12 school may have some policies within school district or state board of education
  - Community youth leagues: league or state specific if tied to board of education
Sport
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  Some sports have limited or no NCAA guidelines or resources.
Position play
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  NCAA guidelines may vary with regard to the use of protective gear for a particular position within a sport

Abbreviations : AAOS, American Academy of Orthopaedic Surgeons; ACSM, American College of Sports Medicine; NFHS, National Federation of State High School Associations; AAHPERD, American Alliance for Health, Physical Education, Recreation, and Dance.

Athletes are considered to be highly motivated patients because of their dedication to their sports, competitive attitude, high level of fitness, and efficiency with learning novel movements or tasks. However, athletes are often risk takers and an overaggressive attitude (no pain no gain) may lead to premature stress on healing injured tissues. During the protective phase of rehabilitation, the therapist spends the most time with the athlete, so it is the therapist’s responsibility to control the athlete throughout all phases of rehabilitation, and emphasize the need to respect the biology of tissue healing.

Regardless of the mechanism of injury, the rehabilitation principles are the same for all patients and the nuances specific to individual patients, including how they occupy their time, are considered when the plan of care is established. These considerations include activities of daily living, as well as education, occupation, and recreational tasks. Some of the unique considerations for sports rehabilitation are an emphasis on the cause of the sports injury, incorporating sport-specific activities, optimizing skills required for the sport, and providing a holistic conditioning program to improve or maintain the level of fitness, while safely protecting the healing injury.

Rehabilitation phases

The rehabilitation outcome is to return the athlete back to optimum performance as safely and rapidly as possible. Therefore, none of the aspects of rehabilitation should be skipped, especially once clinical healing of the injured tissue is determined. Downtime during the protective phase of therapy may lead to impairments in strength and endurance of the involved upper limb, and the nature of the injury may decrease the overall level of fitness, including impairments in strength and endurance in the noninvolved limbs and core. Premature RTP may put the athlete at risk for repeat injury to the wrist or hand, as well as increasing the potential for a new injury to another part of the body.

Protective Phase: Managing the Acute Injury

Postinjury and postoperative protocols vary with the specific injury. However, the overall therapy objective in this phase of care is to provide a careful balance between protecting the injured or repaired tissues and applying controlled stress. This delicate balance facilitates increases in tensile strength of healing structures, restores motion, modulates pain, decreases edema, and prevents the ill effects of immobilization, such as joint stiffness and muscle atrophy. Although the healing time varies by condition and severity of the injury, athletes generally have an accelerated program because of their general health status, level of fitness, and low incidence of comorbidities that may delay healing.

Surgeons may choose to protect hand or wrist conditions with splints, casts, or commercial braces or they may refer the athlete to a therapist skilled in custom orthotic fabrication to make a protective orthosis. The custom orthosis may be the standard for the specific injury provided the athlete is unable to RTP. Modifications to the standard custom orthosis may be required to allow the athlete to RTP, if appropriate, during the protective phase. The complexity of the injury determines the amount of time needed to control the activity level of the athlete as this phase is initiated.

Controlled therapeutic exercises specific to moving the hand and wrist are emphasized during this phase, but the quality of the exercise may depend on the patient’s willingness to move. Other therapy interventions typically incorporated into the plan of care for patients during the protective phase include interventions that focus on reduction of pain, edema, and inflammation, including physical agents such as electrical stimulation or ultrasonography, therapeutic taping, pain science education, graded mental imagery, and activity modification. General patient education about the scope of injury and expected therapy outcomes are ongoing throughout the episode of care.

Therapists are encouraged to use a biopsychosocial approach when establishing the individualized plan of care for all patients. ^, This approach ensures the therapist can assist in the identification of red flags that affect the athlete’s recovery. High pain scores and psychological factors, such as anxiety or depression caused by the impact of injury, have been associated with poor recovery outcomes and chronic pain. Although specific guidelines for hand and wrist injuries may not list therapy as a primary treatment of acute pain, the use of therapy for chronic pain management has been established as an alternative to opioids in prescribing guidelines. ^, Future investigations regarding therapy during the acute protective phase of rehabilitation may show a reduction in the use of opioids, especially in athletes eager to RTP.

A conditioning program that focuses on maintaining premorbid fitness level should be developed in a safe and controlled manner to minimize risk to the healing tissues. The specifics of a conditioning program depend on the complexity of the hand or wrist condition, but the program should include aerobic exercise and lower extremity (LE) strengthening exercises to maintain muscle strength, power, and endurance. A strengthening program for the noninvolved upper extremity (UE) and the noninvolved muscle groups of the injured hand and wrist should be tailored to the athlete without risking further injury. The athlete may need to wait 4 to 12 weeks before vigorous sports-specific activities can be resumed.

It is beyond the scope of this article to address the specifics of postoperative protocols for flexor/extensor tendon repairs, carpal ligament injuries, and intra-articular phalangeal fractures. This information can be found elsewhere. During the protective phase, the acute management of hand and wrist injuries does not vary much between athletes.

Postprotection Phase: Preparing for Safe Return to Play

Following the protective phase of rehabilitation and the clinical healing or union of injured structures, athletes progress to strengthening exercises, proprioceptive training, and sport-specific activities simulated in the clinic under the supervision of the therapist. If relevant, the athlete is asked to bring in equipment used for the sport. Although the hand and wrist might be the primary site of injury, the functional use of the involved upper limb or both upper limbs may have been discouraged. Total arm strengthening exercise programs, commonly used for shoulder and elbow conditions, benefit athletes with a wrist or hand injury. Recognizing that the tensile strength of the injured tissues is not fully restored at this phase, care must be taken to progressively increase the resistance to not overload the muscles of the injured limb.

UE weight-bearing tolerance is another essential component in the postprotection phase. Athletes, especially those involved in leisure, club, or intramural sports, usually ask their therapists when they can return to their sport-related activities. If the patient has sustained a fracture, ligament, or tendon injury of the hand and wrist, weight-bearing through the involved upper limb may be prohibited for about 4 to 12 weeks during the protective phase. Because the FOOSH is a protective mechanism associated with loss of balance and falls, before RTP, the athletes must be able to tolerate UE weight-bearing during high-level conditioning activities such as running on uneven surfaces. Fig. 1 A–F shows an UE weight-bearing sequence used by this author.

In general, the athletes participate in some low-level strengthening and conditioning during the protective phase. Depending on the restrictions placed on the athlete during the protective phase, the level of fitness, LE conditioning, and core strength may also be diminished. The emphasis during the postprotection phase is to reduce kinesiophobia, restore neuromuscular control, improve the components of muscle performance (strength, power, endurance), and restore the athletes’ confidence in their performance levels. Once cleared to resume total body strengthening and conditioning, it is best to refer the athlete to a physical therapist, athletic trainer, and/or coaches. The therapist that has been managing the hand and wrist injury should continue to consult with these team members to address any lifting or weight-bearing restrictions.

The final part of this phase involves a collaborative effort between athlete, therapist, athletic trainer, and coaching staff. All of the activities in this phase are involved in restoring the athlete’s work capacity without causing stress to the healing injury. Work capacity is defined as the athlete’s ability to perform repetitive technically proficient sports skills and exercise without the onset of excessive fatigue. High-level sports-specific activities to optimize performance and safe RTP are progressed as strength and endurance improve. However, there are no specific guidelines available for hand or wrist injuries in any sport; therefore, team communication is essential to optimize the athletes’ recovery. Sometime during this final phase, the need for hand therapy will decrease to consultation to address tissue reactivity ( Box 2 ) while performance is building, and determining the need and value of protective orthoses, braces, or supportive taping.

Box 2

Signs of tissue reactivity

Signs of inflammation (pain, edema) at rest
Increased pain with motion or activity
Decrease in motion caused by pain

Orthotic intervention

Orthosis is the term used by therapists to describe an externally applied device fitted to the hand or wrist. It may be custom fabricated by a therapist or prefabricated from commercial distributors but fitted and/or adjusted by the therapist. The application of the orthosis includes patient education for use, wearing schedule, hygiene care, and review of precautions. The therapist evaluates the need for the orthosis and determines whether the selected orthosis achieves the intended purpose. Orthoses may be used to protect an injury or repaired tissues, provide support to reduce pain, provide mobilizing forces to improve passive motion, and provide substitution for impaired muscle function following peripheral nerve injury. The variable nature of sports-related injuries may require the use of an orthosis for any of these purposes through the rehabilitation process.

Mobilizing orthoses are typically indicated following required, prolonged immobilization for complex hand injuries. Adhesion formation and limited mobility may cause joint contracture or tendon tightness that restrict joint range of motion (ROM). When therapeutic exercises, especially passive stretching, fail to resolve the limitation in motion, a mobilizing orthosis can be applied to provide a low-load prolonged stretch. Mobilizing orthoses are commonly used to improve limitations in passive flexion, extension, or supination. The wearing schedules vary by the degree and direction (flexion, extension) of limited motion, the end feel of the passive limitation, and the joints involved. For example, to improve extension of a joint, the mobilizing orthosis may be worn during sleeping (6–8 hours). Orthoses that are fabricated to improve flexion or supination are typically used intermittently throughout the day for 15 to 60 minutes for a total time of 2 to 8 hours depending on those factors previously mentioned, as well as the joint’s response to the stress application.

As mentioned in the protective phase, the use of standard orthoses for wrist and hand injuries is common. If the athlete is able to participate in practice, a duplicate orthosis can be fabricated. When it is fitted to the athlete before practice, extra strapping, taping, and padding are used to protect vulnerable structures. After practice and bathing, the practice orthosis is removed and the original standard orthosis is reapplied, which ensures compliance during regular daily activities because the practice orthosis is likely bulky and malodorous.

Rigid or semirigid orthoses intended for use during competition must comply with the rules and regulations of the applicable regulatory agency. For collegiate athletes, this is the National Collegiate Athletic Association (NCAA). The NCAA has established guidelines for both mandatory protective equipment and special protective equipment for many sports. In general, if the orthosis may harm another athlete, it is prohibited. Some sports, such as football, permit the use of rigid orthoses that are covered in padding. The orthosis must be covered on all exterior sides and edges with foam padding, 12.7-mm (0.5-inch) thickness ( Fig. 2 A–C) Not all football players, such as the quarterback or wide receiver, are able to wear padded rigid orthoses on their hands or wrists because of the bulky nature and the hand function needed for their playing positions. Therapists need to be aware of participation regulations. They also need to be realistic and creative to identify the best options to protect the injury but permit skillful use of the hand when needed. ^,

The availability of prefabricated orthoses and braces has increased to meet the demands of active lifestyles. Marketed to manage simple musculoskeletal disorders of the hand and wrist, physicians and therapists have identified indications for their use with their patients, especially athletes. Many of these braces are fabricated from low-profile durable materials suited for sports-related activities. Commercially available devices are typically less expensive than custom orthoses, so, if the prefabricated orthosis addresses the clinical goal for the athlete, it may be a wise investment to purchase 2; one to wear when the other is washed. Commercial orthoses provide options for therapists not skilled in custom orthotic fabrication and for athletes with limited insurance coverage for custom braces. However, prefabricated orthoses are not available for some of the most vulnerable hand injuries that require full-time protection during the healing phase, such as repaired flexor tendons.

Therapeutic taping and compression garments

Taping techniques are commonly used by athletes to prevent or manage soft tissue injuries. Athletic trainers are skilled in the use of common taping techniques for the hand and wrist to provide joint stability and restrict movement. For decades, standard white cloth tape, such as Coach (Johnson and Johnson, New Brunswick, NJ) and Elastikon (Johnson and Johnson, New Brunswick, NJ) were the only taping products available, and they are still available.

Because of the popularity of elastic therapeutic tape, therapists are also using taping techniques to modulate pain, reduce edema, support weak muscles, and control motion. ^, This highly elasticized tape is applied to the skin with variable stretch over muscles to control specific movements and may be useful for athletes returning to sport after an injury. Although taping techniques for the hand and wrist are theorized to assist with injury recovery and provide support during play, there is a paucity of peer-reviewed evidence showing the value of its intended use. Tape selection is largely determined by the preference and experience of therapists, athletic trainers, and athletes. The support offered by tape decreases with functional use; therefore, reapplication during play may be necessary. Figs. 3 A, B and 4 A, B show examples of therapeutic taping.