Rehabilitation and Reconditioning

Overview

• The Sports Medicine Team

• Types of Injuries

• Tissue Response to Injury

• Exercise Strategies During Recovery

• Case Study

• Take Home Points

Principles of Rehabilitation and Reconditioning

• Healing tissues must not be overstressed

• The individual must fulfill specific criteria to progress from one phase to another during the rehabilitative process

• The rehabilitation program must be based on current clinical and scientific research

Principles of Rehabilitation and Reconditioning

• The program must be adaptable to each individual and his or her specific requirements and goals

• Rehabilitation is a team-oriented process requiring all the members of the sports medicine team to work together

The Sports Medicine Team• Physician• Athletic Trainer• Strength and

Conditioning Coach/Personal Trainer

• Physical Therapist• Nutritionist• Psychologist

Duties of Sports Medicine Team• Physician

– Calls the shots– Game and practice medical

coverage– Injury evaluation and diagnosis– Referrals if necessary– Determine return to play

• Certified Athletic Trainer– Day to day physical health of

the athletes– Injury prevention, management

and rehabilitation– Evaluate, not diagnosis, injuries

Duties of Sports Medicine Team• Conditioning Coach/Personal Trainer

–Injury prevention and rehabilitation

–Invaluable resource for ATC and PT

–Key in returning a player to the field

–Certified through NSCA

• Physical Therapists–Primarily clinically based

–Longer term rehabilitation

Duties of Sports Medicine Team• Nutritionist

– Registered Dietician

– Member of ADA

• SCAN (Sports, Cardiovascular and Wellness Nutritionists)

– Nutrition professionals with expertise and skills in promoting the role of nutrition in physical performance, cardiovascular health and wellness

• Psychologist– Improve performance– Return from injury

Types of Injuries• Macrotrauma • Microtrauma

Macrotrauma

• Injury suffered as result of a specific, sudden episode of overload to a given tissue

• Types– Bone– Joint– Soft Tissue

Compound Fracture dislocation of left ankle after falling 1m from ladder Source: ED, Royal North Shore Hospital

Bone Macrotrauma• Fracture

–A break in the bone or cartilage

• Types–Stress or Hairline–Compound or

Open–Simple or Closed–Avulsion–Compression

Types of Bone Fractures• Stress Fracture or Hairline Fracture

– A very fine crack in the bone• Compound Fracture or Open Fracture

– A fracture in which the bone is sticking through the skin

• Simple Fracture or Closed Fracture– The bone hasn't pierced the skin

• Avulsion Fracture– Tendon or ligament pulls off a piece of the

bone• Compression Fracture

– Occurs when vertebrae in the spine are broken

Types of Fractures Video• http://www.youtube.com/watch?v=7jp7eDYkVq

8&feature=related

Joint Macrotrauma• Joint Dislocation

– Complete displacement (joint surfaces are not in anatomical alignment) of the joint surfaces

• Joint Subluxation– Partial displacement of the joint surfaces and may

result in laxity or instability

Shoulder Dislocation

Dwayne Wade Shoulder Dislocation

• http://www.youtube.com/watch?v=09ZZbJzeKUA

Ligament Macrotrauma• Sprain: injury to the

structures that connect the bones and help maintain joint stability

• First Degree: partial tear of the ligament without increased joint stability

• Second Degree: partial tear with minor instability

• Third Degree: complete tear with full joint instability

Muscle Macrotrauma• Muscle Strain: tear to the fibers of the muscle

–First Degree : partial tear of individual fibers characterized by painful muscle activity

–Second Degree: partial tear of muscle characterized by weak muscle activity

–Third Degree: complete tear of the muscle fibers with painless muscle activity

• A muscle contusion is an area of excess accumulation of blood and fluid in the tissues surrounding the injured muscle

Microtrauma• The result of repeated, abnormal

stress applied to a tissue without sufficient recovery time

• Joint and soft tissue– Tendonitis– Bursitis– Muscle soreness

Tendon Microtrauma

• Tendonitis – Inflammation of the tendon

– Most often due to excessive repetitive movement

• Most common tendons affected– Rotator cuff, biceps, elbow, wrist, hip, knee

(patellar tendon), and ankle (achilles tendon)

• Symptoms– Swelling, pain and stiffness

Bursa Microtrauma• Bursa

– Fluid filled sac located between tendon and bone

– Prevents friction

– 160 in the body

– Majority located in the shoulder, elbow, hip and knee

Bursa Microtrauma• Bursitis

– Inflammation of bursa due to continuous rubbing of tendon over bone

– Most often due to excessive repetitive movement

– Most common bursa affected are elbow, shoulder, hip, knee and ankle (calcaneus)

• Symptoms– Swelling, tenderness and

pain

Muscle Microtrauma• Muscle Soreness

– Acute • Build up of lactic acid, potassium and

other fluids within the muscle causes pain by impeding circulation and stimulating pain receptors

– Delayed Onset Muscle Soreness (DOMS) • Damaged muscle fibers stimulate pain

receptors• Caused by eccentric muscle contraction

Tissue Healing

• Three phases of tissue healing:

–Inflammation Phase

–Repair Phase

–Remodeling Phase

Tissue Response to InjuryPhase One: Inflammation

• Normal reaction that is necessary to the healing process of the body, but excessive inflammation will delay recovery

• 24-72 hrs after injury• Vasodilation• Pain, swelling, and redness• Decreased collagen synthesis• Bradykinin is released which dilates blood

vessels, contracts non-vascular smooth muscle, and causes pain.

• Phagocytosis: macrophages remove cellular debris

Tissue Response to InjuryPhase Two: Repair

• Highlighted by the repair and regeneration of new tissue– Two to three days after injury up to eight weeks

• Tissue repair is accomplished by either:– Regeneration (Replacement of tissue by the same

tissue)• Dead and unviable tissue is removed• New capillaries are formed and collagen fibers are

laid down–Collagen fibers are placed haphazardly, which

can result in sub-optimal strength and athletic performance if not corrected

– The formation of granulated tissue (scars)• Scars are made up of dense, inelastic, non-vascular

fibrous tissue

Tissue Response to InjuryPhase Three: Remodeling

• Overlaps with Repair phase• Strengthening of the new, weak tissue

– Production of new collagen fibers slows

– Collagen tissue begins to hypertrophy and align with the lines of force

– Strength of new collagen tissue continue for up to two years post-injury• Ligamentous tissue can take up

to one year to completely remodel

Exercise Strategies/Approaches• Inflammation Stage

– Exercise is not recommended– Tissue needs time to heal– P.R.I.C.E. Principle should be used for the first 48-

72 hours immediately following the injury. The goal is to reduce swelling, prevent further injury, and reduce pain• Protection• Rest• Ice• Compression• Elevation

• Ultrasound• Electrical Stimulation

Exercise Strategies/Approaches• Repair Stage

–If possible, implement exercises to maintain cardiovascular conditioning (stationary bike, upper body ergometer) and muscular strength (isometric contractions)

• Remodeling Stage–Game on–Sports specific exercises–Proprioception work (balance exercises)–Isotonic strength training (closed vs. open

chained), agility training, etc

Case Study • Shannon Sharpe,

Denver Broncos

• Posterior Elbow Dislocation

• Injury occurred 11-11

• Non-surgical rehab

• Back to practice 11-27 (16 days)

• Back to game 12-8 (27 days)

MRI Results• Disruption of the anterior

capsule with 2-3cm defect of distal brachialis with extensive hemorrhage and fluid

• Tearing/stripping of the anterior bundle of the medial collateral ligament complex, distally greater than proximal

• High grade partial tearing of the common flexor tendon at medial epicondyle and hemorrhage within the flexor pronator musle mass

• Large joint effusion with multiple internal bodies

Rehabilitation ProtocolPhase 1: Inflammation

• Goals– Minimize inflammatory

response

– Protect injury

• Program Components– Hinged

Brace/Compression

– NSAIDS

– Ice and Elevation

– Electrical Stimulation

Rehabilitation ProtocolPhase Two: Repair

• Goals– Speed up tissue repair– Limit loss of range of

motion (ROM)• Program Components

– Passive ROM (Day 2)– Soft tissue massage (Day

4)– Active ROM (Day 5)– Stretching (Day 5)– Myofascial release (Day 5)– Hydro therapy (Day 6)

Rehabilitation ProtocolPhase Three: Remodeling

• Goals–Return to play

• Program Components (Strength)–Manual resistance

wrist, biceps/triceps (Day 7)

–Manual resistance shoulder (Day 9)

–Sport cord biceps/triceps wrist (Day 10)

Rehabilitation ProtocolPhase Three: Remodeling

• Sport cord shoulder (Day 12)

• Weight room biceps/triceps (Day 12)

• Weight room upper body modified (19 Days)– (Ball stabilization

for core/lower extremity-Day 5)

Rehabilitation Protocol• Program

Components (Strength and Proprioception)– Closed chain

seated/standing (Day 8-10)

– Closed chain quad/tripod (Days 11-15)

– Closed chain uneven surface (Day 14)

Rehabilitation Protocol

• Program Components (Sports Specific) – Catching (Day

10)

– Stance (Day 12)

– Running (Day 12)

– Blocking (Day 12)

Take Home Points• The point person for the sports medicine

team is generally a physician• Injuries occur as the result of either macro

or microtrauma• The three phases of tissue healing are

– Inflammation– Repair– Remodeling

• Closed chain exercises (push-up, squat, split squat…) tend to be more sports-specific than open chain