Rehabilitatio

n of Sports  
Injuires

   

   

• Introduction

• Principles of rehabilitation

• Key concepts

○ Team approach

○ Diagnosis

○ Acute injury management

○ Drugs

• Management

○ Passive physical treatments

○ Active physical treatments

 Strengthening exercises

 Flexibility

 Endurance

 Proprioceptive retraining

 Functional training

○ Psychological

○ Biomechanical factors

○ Return to sport

• Rehabilitation of four common injuries.

○ Tennis elbow

○ Sprained ankle

○ Hamstring

○ Stress fractures

• Complications of rehabilitation

• Prevention
‘Life is movement, movement is life’. Aristotle

Introduction
Rehabilitation is a generic term for the comprehensive treatment of injury and/or medical
conditions. It has active and passive elements. It focuses upon the whole person not just the
injury and aims to restore the greatest possible degree of function in the shortest possible
time. The factors implicated in the cause of injury should be addressed to prevent injury
recurrence.

Three concepts help with the understanding of the rehabilitation process these are
impairment, disability and handicap.

Injury causes an individual an impairment. This is the injury at the tissue level e.g. ruptured
medial collateral ligament of the knee.

Impairment usually causes a disability This is a loss of function e.g. walking with a limp and
unable to run.
This in turn may cause a handicap this is an individuals inability to perform tasks or engage in
activities.

e.g. the professional footballer is unable to compete for the rest of the season due to the
knee injury which causes loss of playing time, reducing his income and prematurely ending
his career. This causes some reactive depression.

From this example the need for the physician to consider the medical, physical, psycho-
social, vocational and leisure requirements of the injured athlete is apparent.
The areas covered are
1. the principles of rehabilitation.
2. treatment modalities
3. specific examples
4. complications of inadequate or incorrect rehabilitation
5. prevention

Principles of rehabilitation
The process of athletic injury rehabilitation aims to minimize tissue damage and allow a safe
return to activity. It is based on the science of tissue healing, knowledge of joint
biomechanics, physiology of muscular strength and endurance, and the neurophysiological
basis of skill retraining. Successful programs are based on an understanding of these
constraints, which, when properly applied, permit the progressive activity of joints and
muscles. Muscular strength, endurance and power are redeveloped while flexibility and
cardiovascular fitness are maintained. Precipitating factors are identified and addressed to
minimize reinjury. (1)

To understand, grade and treat injuries the physician needs to identify the tissues involved.
This chapter focuses on muscle-skeletal injury and rehabilitation of bone, ligament, muscle,
tendon, connective tissue and neuromuscular structures combining to produce coordinated,
purposeful movement. The treatment of other injuries is covered in relevant chapters.

The healing process involves inflammatory, repair and remodeling phases. There are
detrimental effects of immobilization, muscle wasting and weakness and subsequent joint
damage. This leads to further immobilization and reflex inhibition ‘a vicious circle’. Early
mobilization is usually indicated.

Lack of motion of joints results in shortening of capsular and other connective tissue
structures supporting the joint, loss of lubrication and alternating compression between joint
surfaces deprives articular cartilage of nutrition.(2)

There are detrimental systemic effects of immobilization, these begin within hours and
become clinically important within days. They include cardiovascular deconditioning, nervous
system depression, skin sores gastrointestinal complaints (constipation), thromboembolic
genesis, bone resorbtion and respiratory impairment.(3) Thus the expression ‘MOVE IT OR
LOSE IT’

An understanding of the sport or activity is required, many injuries are sport specific and
communication is enhanced if the physician has some basic knowledge of the sports
requirements. ‘Profiling’ is a concept that matches an individuals physiognomy with the type
of athletic activity and in team sports their role.
1 Kulund ‘The Injured Athlete’ Lippincott 1988
2 C Hubley-Kozey et al.1994.Rehabilitation Principles and Techniques.In JC Delee et al Eds
Orthopaedic Sports Medicine Chapter 6 p 184-207.Saunders Philadelphia
3 Krusen’s Handbook of Physical Medicine and Rehabilitation 3rd Ed Saunders1971

Key concepts

Team Approach
Rehabilitation is facilitated by a team approach. The basic team comprises in order of
importance

• The injured athlete.

• The physical therapist- physiotherapist have the most scientific training (other types
 include masseuse)

• The doctor.

• Others; orthotist, brace maker, strapper, coach, exercise trainers, dietitian,

psychologist, dentist, nurse, first aid personal, peer group, family and friends.

Diagnosis

History present injury, past, athletic, social, family

and psychological histories where required

Examination including measurement of impairment and

function, comparison with unaffected limb

and review of biomechanical factors.

   
Investigations this may include specific functional tests,

pathology, radiology and nuclear medicine

investigations where appropriate

Problem list particularly if the injury is complex or

severe(4).

   
Acute injury management (Table 1)
Begins immediately and can be performed by the athlete or any other capable person. This
phase lasts the first 24-48 hours. It consists of protecting the individual from further harm,
resting, and icing the injury. Compression and elevation are used to minimize edema and
haemorrhage and drugs are used for analgesia, anti-inflammatory properties and muscle
spasm relief. Acute injury management is summarized by the acronym P R I C E.
Occasionally more extensive treatment or surgery is required.

4 Stolov W ‘Evaluation of the Patient’ in Krusen’s Handbook of Physical Medicine and Rehabilitation 3rd Ed

Saunders1971

Drugs
In general the authors feel that drug use should be minimized and the other components of
injury management emphasized. Drugs used in rehabilitation of sports injuries are of four
main groups.
1. Analgesics - paracetamol, codeine, opiates and local anesthetic agents.
2. Anti- inflammatory medications are used extensively and have analgesic properties as well
as causing moderation of the inflammatory response to injury. A short course of 3-7 days can
be useful. Compliance is better with once or twice daily dosing. Topical and parental
antiinflammatory medications are now available. Gastric ulceration, hypertension and renal
impairment are among the side effects.
3. Anti spasmodics and sedatives are utilized to reduce muscle spasm and consequent pain,
stiffness and immobility in the first 48 hours. They also induce drowsiness and can aid sleep.
Benzodiazepams are used with caution as they affect balance, coordination and judgment(5).
4. Corticosteriods are usually used in chronic injuries. They have anti inflammatory,
immunological and metabolic effects. They are injected intra-articularly or into connective
tissue around tendons e.g. in subacromial bursitis. Their efficacy has been established(6).
There are severe potential complications such as septic arthritis and tendon rupture these
agents should be used by experienced practitioners only. Do not use on the Achilles
tendon(7).

5 Goodman and Gillman The Pharmacological Basis of Therapeutics 8th Ed Pergamon Press 1990

6 Nelson K Briner W Cummins J Corticosteroid injection therapy for overuse injury Am Fam Phy 1995 52(6)

1811-6

7.Shrier I Matheson G Kohl H Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport

Med 1996 Oct 6(4) 245-250

Management

Passive physical treatments

Ice )
Heat )
Ultrasound ) used alone or in combination
T.E.N.S. )
Laser )
Manual Therapy )

Ice has beneficial effects in the acute and intermediate phases(8). Cold decreases spasm
and slows nociceptor nerve conduction. Once swelling and pain have diminished sufficiently,
ice is combined with active and passive range of motion within pain tolerance. The ice is used
both prior to and during the therapeutic exercise session. This is done for 20-30 minutes
twice a day. In between the injury site is protected. Induce analgesia with ice for 20 minutes,
exercise (static stretch, isometric contract, static stretch), rest 30 seconds and repeat (2-3
times) several times per day. Once the effects of swelling and pain have subsided and the
athlete has progressed to more vigorous exercise and functional activity, the ice is used for
20-30 minutes after the therapeutic exercise bout. Ice can cause burns and superficial nerve
palsies (peroneal and ulnar)

Ice pack; Plastic bag, crushed ice, tea towel. Caution should be exercised with Gel packs
which freeze below 0 Centigrade. These should be wrapped in toweling.

Heat causes vasodilatation (increased delivery oxygen, nutrients and immune mediators) and
increased metabolic rate, altered pain sensation, increased collagen extensibility, better
nutrition and decreased sensitivity to muscle stretch(9). Acute use helps relieve muscle
spasm. Most useful for chronic inflammation, joint stiffness, pain syndromes.

May cause increased edema and local burns and should be supervised by the physical
therapist.

Modern use of heat relies on hot packs 40-70 degrees applied for 20 minutes in conjunction
with range of motion exercises. The widespread use of rubifactents to cause peripheral
vasodilatation and local heating is not recommended due to the relative difficulty in controlling
timing and dosage.

8 Hillman and Delforge The use of Physical Agents in the Rehabilitation of Athletic Injuries Clinics in Sports

medicine 4/3 July 1985

9 Lehmann J Therapeutic Heat and Cold 3rd Ed. Williams and Wilkins 1984

Ultrasound. High frequency soundwaves 0.8- 1.1MHz, produce heating at fascial planes.
When pulsed at low frequency ultra sound produces a mechanical effect. Together they
produce an analgesic and anti-inflammatory effect by increasing local perfusion and
metabolism(1).Thrombolysis is aided and there is a role in haematoma treatment(11). There
are complications of overzealous or incorrect treatment. Usually employed after the acute
phase.(12)

TENS transcutaneous electric nerve stimulation produces analgesia and is used extensively
in chronic pain syndromes(13).

Works via spinal gate mechanism and direct effects on nociceptors.

Indifferentual is a form of TENS in which alternating electrical stimulation is used to produce

various levels of muscle contraction. This reduces the edema and helps minimize disuse
atrophy. There is some evidence that it has antispasmodic action in spinal injury patients(14).

Laser Cold laser is used for small localized lesions (e.g. long head biceps strain) It is claimed
to reduce pain and spasm and have beneficial effects on local metabolism. Evidence exists
for alteration of nerve conduction(15) but is absent for clinical effect in well controlled in vivo
studies(16).
10.Gam and Johannen Ultrasound therapy in musculoskeletal disorders: a metanalysis Pain 1995 Oct 63(1) 85-

91

11 Luo et al Transcutaneous ultrasound augments lysis of arterial thrombosis in vivo Circulation 1996 Aug 15

94(4) 775-8

12 Falconer et al Therapeutic ultrasound in the treatment of musculoskeletal conditions Arthrit Car Res 1990

June 3(2) 85-91

13 Wall and Melzeck Textbook of Pain 2nd Ed C-Liv 1989

14 Goulet et al Effects of transcutaneous electrical nerve stimulation on H reflex and spinal spasticity Scand J

Rehab Med 1996 Sep 28(3) 169-176

15 Baxter et al Effects of low intensity infrared laser irradiation upon conduction in the human median nerve in

vivo Exp. Physiol 1994 March 79(2) 227-34

16 Mokhtar et al Double blind placebo controlled investigation of the effect of combined phototherapy/low

intensity laser therapy upon experimental ischaemic pain in humans Lasers Surg Med 1995 17(1) 74-81

Manual therapy. This differs from the above modalities in that it requires the therapists to use
their bodies on the patient. Manual therapy encompasses all forms of massage, mobilization,
manipulation, traction and neural stretching. The ultimate manual treatment consists of
surgery. The individual techniques and combinations applied vary and are beyond the scope
of this chapter.

Manual therapy is the most ancient form of medicine the ‘laying on of hands’ Several
practitioner groups make claims that are unscientific and misleading. The authors
recommend that athletes be guided to therapists who have scientific training, experience in
sports injury and who can work in a team. There are potential risks with manual therapy,
particularly rotational spinal manipulation which has caused disc prolapse, corda equina
lesions and vertebral artery dissection (17,18).

There are clear benefits in reduction in muscle spasm and edema, relaxation, flexibility and
increased joint range of motion from manual therapy. There is also a placebo effect in some
patients. Psychological benefits of manual therapy are often observed.

17 Padua et al Radiculo medullary complication of cervical spinal manipulation Spinal Cord 1996 Aug 34(8) 488-

92

18 Assendelft et al Complications of spinal manipulation: a comprehensive review of the literature J Fam Pract

1996 May 42(5) 475-80

19 Maitland G Peripheral Manipulation 2nd. Ed. Butterworths 1987

20 Knapp M. Massage Krusens Handbook of Physical Medicine and Rehabilitation 3rd Ed. W.B. Saunders 1982
Active physical treatments

Active physical treatment is the foundation of the rehabilitation process. When an injury
occurs immobile muscle rapidly atrophies, connective tissue contracts and detrimental joint
changes occur. Active physical treatment requires the interest and compliance of the athlete
to minimize injury consequences and return to activity.
Strengthening exercises (Fig 1-14).

These aim initially to minimize disuse atrophy, increase circulation and maintain muscle
condition. As healing continues gains in strength, control, co-ordination and endurance
facilitate recovery. There are several types of strengthening exercises and these are
combined for maximum effect(21,22).

Isometric These exercises are conducted without movement across the joint on which the
muscle acts. There are two program types prolonged contraction involves a 20 - 30 second
contraction performed 10 -20 times with a 20 second break. These can be performed from
the acute phase of injury up to 10 times per day. Basmajian (21) recommends brief (5-6 sec)
repeated isometric maximal (added weight) exercises with a 20 sec delay. This minimizes
cardiovascular stress (hypertension) which has been observed with prolonged isometric
exercise. Isometric exercise can be performed with the joints in various angles and achieve
improved strength of muscle.

Isotonic In which muscle contraction moves a joint through a range of motion. Thus if the
muscle shortens while contracting (e.g. biceps curl) it is termed a concentric contraction. The
act of lowering a weight from height (e.g. lowering a biceps curl back to the start position) is
termed eccentric as the muscle is lengthening while contracting.

Daily progressive resistance exercise (P.R.E.) using weights or other resistant devices is
prescribed and begins after the acute phase. Multiple repetitions are used and the number
and resistance can be varied(22). The tempo or rest periods can also be progressively
altered. Careful instruction and supervision is required. Typical examples are provided later.

A variety of machines have been designed to improve strengthening throughout the joint
range for different muscle lengths. One type is a command system with increased weight at
mid range and reducing at full extension and flexion (Nautilis)

Various machines have been developed to perform isokinetic exercise.

This allows constant velocity with variable resistance as the muscle move the joint through its
range. An example is the isokinetic dynamometer machine which was originally designed for
rehabilitation of knee injuries. It can be applied to any joint.

Balance around a joint is essential in any exercise program with a balanced ratio of agonist
and antagonist training(21). Coordinated patterns of training are covered in functional
training.

Plyometric exercises are also useful in developing muscle power .They use a stretch-
shortening cycle to elicit a more forceful concentric contraction. Associated with rapidly
changing eccentric to concentric action, it has been suggested that they may develop
reciprocal reflex training which may be useful in injury prevention. It is used 2-3 times per
week but discontinued if the athlete develops pain, swelling or other signs of overuse. It has
also been employed as a strengthening technique in uninjured athletes.

21 Basmajian Therapeutic Exercise 4th Ed Williams and Wilkins 1984

22. RM Poole Therapeutic Exercises for the Injured Athlete 1994 Appendix VII p599 in Sports medicine for the

Primary Care Physician 2nd Ed RB Birrer Ed CRC Florida

23 Schram D Resistance Exercise Therapeutic Exercise Mc Master University 1980

Flexibility

Flexibility exercises have two benefits. First in allowing and encouraging joint ROM exercises,
they are a factor in return of normal joint mechanics. Second the effect of graduated
stretching over time increases the length of contractile units and connective tissue elements
within the muscle. As the muscle, tendon and enthesis are part of the same contractile unit
this helps reduce injury. Blood supply to the tendon is predominately from the muscle with
less from the bone attachment/enthesis. There is a critical area in the tendon which is
susceptible to injury and ischaemia(24).

Flexibility exercises have the effect of improving the efficient range of muscle contraction and
preventing avulsion at tendon bone junction by reducing the chance of end range ‘bow
stringing’. After injury stretching after physical therapy such as ice or heat reduces the activity
of the fusimotor system, provides analgesia and often allows a greater ROM(25).

Stretching regimes are from 30~60 seconds; times 3 repetitions; twice daily. Ballistic
(bouncing) exercises or passive stretches by weights machines or trainer, run the risk of
muscle tears. A slow stretch and creep technique is preferred, progressive to the limit of
discomfort and NOT beyond. The desired muscle length may require twice daily stretching for
six weeks with maintenance once daily. Specific stretching exercise programs are available in
many forms. A basic lower limb stretching is provided(Fig 15).

Proprioceptive Neuromuscular Facilitation Stretching (PNF) reduces muscle tone by

stimulating the Golgi tendon organs. It relies on synergies using agonists activities to relax
antagonists. PNF involves Proprioceptive and tactile techniques to cause muscle relaxation
and repetitive activities to establish patterns of muscle contraction(17).

Various movement and flexibility paradigms are prompted by diverse groups. These include
yoga, Bowen and Alexander techniques and Feldenkrais. The authors believe that each has
its merits although blindly following the teachings of self promoting ‘gurus’ is unscientific.
24 Takami et al Traumatic rupture of the extensor tendons at the musculo-tendinous junction J. Hand. Surg. Am.

May 1995 20(3) : 474-7

25 Ganong Review of Medical Physiology 17th Ed 1995 Appleton and Lange

Endurance

Endurance refers to the ability of a muscle to perform a static (isometric) or dynamic

(isotonic) task. It depends on the state of the individual muscle and the cardiovascular status
of the individual.

A guide to endurance can be made by using physical work capacity measures, or pulse
verses workload. A linear relationship exists between oxygen uptake and pulse rate. Using
the Astrand nomogram a predicted VO2 maximum may be determined (26).Other protocols
have been used in cardiovascular testing. An example is the step test whereby the number of
steps of a given height from the floor, up to a bench, taken in a given period is recorded.

As a minimum cardiovascular and endurance training should occur 20 minutes, 3 times

weekly . Most athletes will easily exceed these guidelines. For an in depth description of
cardiovascular fitness and aerobic exercise readers are referred to exercise physiology texts.
The benefits include cardiovascular training, metabolic stimulation, maintenance of muscle
bulk release of endocrine hormones and immunological modulation. There is evidence that
endurance training of unaffected body parts has trophic effects on the injured area. It also
may have positive psychological effects in individuals (27).

Many methods are available to provide aerobic and endurance training for the injured athlete.

They include:

• Swimming

• Water exercises(hydrotherapy)

• Brisk walking

• Circuit training

• Calisthenics/ Aerobics

• Stationary bicycles

• Machines (stepper, rowing, arm crank etc)

Swimming is the preferred exercise in most cases as the activity is non weight bearing and is less prone to re

injury. The particular regime will depend on the site, nature and age of injury and on the individuals

circumstances and skills.

26 Astrand and Rodahl, Textbook of Work Physiology Physiological Basis of Exercise Mcgraw Hill 1986

27 Dickinson and Benett Therapeutic Exercise Clinics in Sports medicine 4/3 July 1985

Proprioceptive retraining
Ligaments and to some extent tendon injuries are accompanied by an impairment of
proprioception which may persist after the inflammatory phase of the injury is resolved (28).
The three cues to balance are vision, vestibular function and lower limb position sense -
proprioception.

Following an injury, position sense of a body part in relation to space or other objects is often
diminished or lost. The goal of proprioceptive exercises is to reduce the time between neural
stimuli and muscular response, thus reducing the stress on the injured joint during functional
activities. Rehabilitation of injuries to the knee and ankle require proprioceptive retraining.
Whiplash injuries cause abnormal neck proprioception and upper limb injuries may also
require retraining.

The components of lower limb proprioceptive training include:

• Taping or external supports to provide increased sensory input and protection during
the early phases.

• Static balance exercises standing on one leg initially then graduating to less firm
surfaces e.g. foam and eventually wobble board.

• Reduction of visual cues using blindfold or distracting activities during balance

exercises e.g. throwing a ball to and from trainer or against a wall and catching.

• Dynamic training such as jogging in soft sand progressing to figure of eight or zig
zag patterns. During the later stages of recovery jogging on firm surfaces then finally
uneven surfaces

28 Leanderson et al Proprioception in classical ballet dancers A prospective study of an ankle sprain on

proprioception in the ankle joint Am J Sports Med 1996 May-June 24(3) 370-4

Functional training

Functional training begins as the healing process allows. It is composed of the components
already mentioned. Strength, flexibility, propioception and endurance are required (11).

Muscle groups are exercised in tandem allowing coordinated purposeful movement. Specific
weakness patterns and technique errors can be addressed. This then has benefits on
strength and endurance allowing further functional training. These exercises may begin with
partial squats, leg presses, step-ups, lunges, or closed-chain terminal knee extension. As
symptoms subside and function improves devises such as reciprocal (vertical or stair)
climbers, lateral slide boards, treadmills are used. A progressive walk-jog-run program can
begin as healing proceeds.

For Example, a basketball player with a knee injury could perform a compound exercise such
as a set of body weight squats, when pain free. This could progress with increased weights
and gradual introduction of standing jumping exercises. This could be enhanced with a
plyometric program of exercises.

Functional Training can be general or sports specific. It can be supervised by trainers, therapists, coaches or

parents. Athletes enjoy it and it is part of a graduated return to full activity. It is useful for acute and chronic

injuries. It has been shown to decrease time off employment and speed return to sport(29).

29 Karlsson et al Early functional treatment for acute ligament injuries of the ankle joint Scand J Med Sci Sports

1996 Dec6(6) 241-5

Psychological

The athlete with an injury requires consideration, understanding and empathy. They may be
suffering not only an injury but financial and emotional stress. Body image is very important to
athletes as well as the endorphin drive they have to exercise. Research suggests that
athletes respond to injury with mood disturbance and lowered self-esteem(30). Calm
explanation of the diagnosis, education and involvement in the rehabilitation plan are
important parts of the therapeutic relationship(31). More time is often required than with other
patients but the usual excellent results offer the clinician satisfaction.

The recruitment of the athlete to taking an active role in their rehabilitation will facilitate the
process.

In extreme cases a reactive depression or post traumatic stress may intervene(30). These
may be treated by supportive psychotherapy and appropriate medication.

Following physical recovery confidence and athletic performance may be slower to return.
Education ,explanation and support are required. A Sports Psychologist may help.

30 Smith Scott and Wiese The psychological effects of sports injuries coping Sports Med 1990 Jun9(6) 352-69

31 Smith et al Emotional responses of athletes to injury Mayo Clin Proc 1990 Jan 65(1)38-50

Biomechanical factors

Understanding the mechanism of the injury will help modify the activity to prevent reinjury. If
this is not corrected adaptive protective behavior may lead to a second and apparently
unrelated injury. Biomechanical factors can be assessed by attending the events and being
involved as team doctor. A detailed history and examination of the athlete is essential. Some
sports have inherent physical demands which cause particular injuries e.g. female
gymnastics forces girls to hyper-extend their backs and weight bear on the upper limbs
leading to injury rates approaching 30% per year!(31).
Some injuries are caused by combinations of athletic activity, technique and individual
anatomy. Plantar fascitis in which biomechanical factors are crucial in the prevention
,treatment and rehabilitation is a good example(33).

Subtle abnormalities at a high level of skill may only be diagnosed by video, gait and force
plate analysis. A coach may help in these areas for technique advice. Foot wear modifications
may be the logical starting point for runners. e.g. ilio tibial band friction syndrome may be
improved by reducing tibial rotation by insertion of an anti-pronation shoe or orthoses (34).

32 Lindner and Caine ‘injury patterns of Female Competitive Club Gymnasts’ Can J Sport Sci. 1990 Dec; 15(4) :

254-61

33 Chandler and Kibler A biomechanical approach to prevention, treatment and rehabilitation of plantar fasciitis

Sports Med 1993 May 15(5) 344-52

34 Rose G Orthotics Principles and Practice William Heineman 1986

Return to sport (Table2)

When the components of the rehabilitation process have been applied correctly the synergist
nature of the treatment should enable return to sport.

After a subjective assessment from the therapist or trainer that the athlete is able to use the
injured extremity well. The athlete's ability to demonstrate enough self-confidence to fully
participate in these activities without experiencing pain, swelling or giving way is assessed.

The athlete progresses to sports-specific activities in a noncompetitive environment. Their

performance should be critically evaluated by the rehabilitation team. Specific stress testing
may be performed.
Rehabilitation of four common injuries.

Tennis elbow

Tennis elbow is an enthopathy. It is also known as lateral epicondylitis

Inflammation occurs at the common extensor origin of the wrist and finger extensor muscles
on the lateral humeral epicondyle.

On the first presentation Rest , Ice, Compression, Elevation and optional drug analgesia is
provided.

Within 24 hours the program is begun. Stretching the extensor and opposing flexor groups of
muscle is taught. This is followed by a graduated weight training for forearm and wrist
consisting of sets of 20 repetitions with weights ranging from 100gm to 500gm for each
movement of the wrist, that is flexion, extension, pronation, supernation and radio-ulnar
movement. This regime is aimed at improving strength and endurance in the muscles and
increasing the range of movement in the joints. The regime is repeated 4 times daily with ice
applied over the lateral epicondyle for anti inflammatory and pain relief at the end of each
session(35).

Passive treatment such as ultrasound, indifferentual and gentle massage may help. Anti-
inflammatory drugs are sometimes employed.

Bio-mechanics may be altered by a change in wrist action during backhand and increasing
the size of the racket grip by wrapping with layers of tape and foam.

Maintaining range of motion in the shoulder and cardiovascular fitness can be achieved by
swimming sessions (crawl or backstroke) 30 min 2-3 times weekly. Active participation in
running, cycling or other aerobic activities is encouraged.

Psychological issues can usually be resolved by explanation, education and providing

support.

Rehabilitation of this injury may take 6-8 weeks(35).

35 Wilson Assessment and rehabilitation of repetitive strain injury in a clinical setting J Occup health Safety

1985 (2)126-9

Sprained ankle

The most common ankle injury is an anterior talo-fibular ligament strain on the lateral side.
More sever injuries cause damage to the calcaneal-fibular ligament with the possibility of
medial deltoid ligament injury as the ankle is forced through more extreme inversion.

After the immediate period of PRICE see table 1, diagnosis and exclusion of fracture occur.
Appropriate antiinflammatory and analgesic measures are taken and a rehabilitation plan
implemented.

Initial treatment days 2-5 focuses on protection with reduced weight bearing, oedema
management and analgesia. Passive physical treatment is used together with medication and
gentle active range of motion exercises.

Simultaneously cardiovascular and endurance training using the unaffected limbs

commences.

Weight bearing proprioceptive retraining is required commencing 5-7 days post injury. The
program involves twice daily sessions of standing on one leg at a time for periods from 1 to 5
minutes. Once standing has been achieved, then distraction of visual cues to balance such
as standing on one leg and throwing a ball against the wall, bouncing and catching drills are
used. This can be progressed with the athlete standing on a wobble board. These sessions
increase to twenty minutes twice daily. At the same time that static proprioception is being
achieved, dynamic proprioception will be promoted by jogging in sand. Progressing to figure
of eight running , jog run, sprint cycles and rapid changes of direction on a variety of soft,
hard and uneven surfaces(36).

The proprioceptive retraining can be facilitated by ankle strapping or bracing which provides
increased sensory feedback and some protection from over inversion movements.

The total treatment time varies by individual and sport but most injuries take from 2-4 weeks
to functional return. Karlson et al report excellent results from early aggressive proprioceptive
and functional retraining with mean return to sport in treatment group of less than 10
days(29).

36 Seto and Brewster Treatment approaches following foot and ankle injury Clin Sport Med 1994 Oct 13(4) 695-

718

Hamstring

The hamstring muscles run from the pelvis and posterior femur to the tibia and fibular head.
They contract concentrically to extend the hip, flex the

knee and contract eccentrically for pelvic stabilization and during the gait cycle. Because of
their long length and crossing of two joints (hip and knee) they are susceptible to muscle and
connective tissue tears and recurrent injury(38)..Strains often occur during periods of
acceleration. Prevention by pre warming stretches and warm ups is encouraged.

After the initial period of PRICE (see table 1) and diagnosis a rehabilitation plan is formulated.

Local passive treatment such as ultrasound and massage is commences with the therapist.
Anti-inflammatories may be prescribed. Isometric exercise can begin within 24 hours.

A graduated stretching program is begun(39). Stretching of hamstrings using stretch and

creep technique for 30 -60 seconds times 5 repetition times twice daily with quadriceps and
tendo achilles stretches essential.

Simultaneously progressive resisted exercise (PRE), is prescribed based on a 10 repetition

set repeated 2-3 times performed daily. Resistance is progressively increased as pain allows.
Icing is combined with the stretching and exercise program.

Balance must be achieved around the knee at a ratio of 60 quadricepts/40 hamstrings.

Therefore PRE is used to maintain quadriceps and calf muscle condition. Isokinetic exercise
if available may speed muscle strength return.

Biomechanical factors such as pelvic alignment, leg length and gait patterns may need
review. Aerobic exercise to maintain endurance and cardiovascular fitness is integral.
Swimming or other injury protecting forms are used.

As recovery proceeds functional exercises such as squats, jogging, running and sprinting are
reintroduced into the program. Caution is required as hamstringing injuries seem prone to
recurrence.

37 Worrel Factors associated with hamstring injuries. An approach to treatment and preventative measures

Sports Med 1994 17(5) 338-45

38 Upton et al Thermal pants may reduce the risk of recurrent hamstring injuries in rugby players Br J Sports

Med 1996 Mar 30(1) 57-60

38 Taylor et al The effects of therapeutic application of heat or cold followed by static stretch on hamstring

muscle length J Orthop Sports Phys Ther 1995 May 21(5) 283-6

Stress fractures

These are overuse injuries typically in the lower limb of endurance athletes. They are caused
by repetitive cyclical loading of bone which exceeds its repair capability(40). They occur most
commonly in the tibia, malleoli and metatarsals (March fractures)but have been reported at
other sites.. They cause pain and disability. If training continues stress fractures can progress
to complete fractures. There is considerable variation in susceptibility to such overtraining
injuries.

Diagnosis is confirmed by x-ray, bone scan, CT or MRI alone or in combination.

The principle treatments are rest, maintenance of cardiovascular fitness and correction of
underlying biomechanical factor.

Endurance/cardiovascular fitness is maintained by non weight bearing exercise e.g.

swimming, water exercises, circuit classes and machines. Rest is required. If compliance is
poor use a POP to immobilize the limb. Walking for usual daily tasks is not detrimental. Some
fractures e.g. navicular require strict NWB(41).Others e.g. anterior tibial epiphyseal stress
fractures may require surgery.

Education, counselling and support are the keys to treatment of stress fractures. The
psychological concerns of these athletes must be addressed.

Problems focused, behaviourally based regimes to reduce uncertainty are

recommended(30).The athlete must be alerted to the tissue limitations from training. Over
training has detrimental effects on the immune system and endurance with poorer
performance and high injury rates.

Confidence of the athlete and compliance with treatment will be more likely if the sports
physician is specific about periods of complete rest and a guaranteed return to training with a
rehabilitation training schedule.

40 Reeder et al Stress fractures Current concepts of diagnosis and treatment Sports Med 1996 Sept 22(3) 198-

212

41 Khan-KM Brukner PD Kearney C Fuller PJ Bradshaw CJ Kiss ZS Tarsal navicular stress fracture in athletes

Complications of rehabilitation

The commonest problem is reinjury occurring due to return to sport before injury recovery is
complete. This may be due to the athlete, inadequate rehabilitation or external pressure such
as coaches. Other injuries may occur due to athletes trying to protect their original injuries
and subsequent altered behaviour or biomechanics. Injury may occur in another area from
trying to protect the primary injury. Over aggressive rehab may be detrimental.

Myositis ossificans occurs in some young athletes following a blow to the thigh and
subsequent quadriceps haematoma. Haematomas are common injuries in the contact sports.
Overzealous stretching, strengthening and massage can provoke a further haemorrhage
which promote fibroblasts to differentiate into osteoblasts and for formation of bone within the
haematoma. This can lead to pain, decreased range of knee motion and residual disability.

Drug treatment always carries significant risk of side effects. Passive physical treatment can
cause injury if incorrectly applied.
Failure of rehab may precipitate psychological and emotional distress.

Prevention

The prevention of injury is important. The duty to the patient is greater than the team or
sporting event. If injury occurs assess prior to continuing. If health is in danger, discontinue
the activity.
General principles:

• Adequate training and preparation prior to competition(weeks/months)

• Consider body physiognomy, maturity and experience to compete. ‘Profiling’ is a

concept that matches an individuals physiognomy with the type of sport and in team
sports to their role.

• Sports facility factors. Such as state of competition area, equipment maintenance,

injury treatment equipment and air pollution.
 • Rules and aims of sporting contest

Individual Factors:

• Treat illness or injury

• Some athletes should be prevent from high risk sports (e.g. epileptics should not
scuba dive)

• Maintain equipment

• Adequate warm-up(stretching, cardiovascular and psychological preparation)

• Protective equipment used

Table 1

Protection is to prevent further injury and may involve the use

of tape, padding or external supports

Rest is relative; the injured body part is ‘rested’ while the

unaffected parts are exercised. Rest should not

mean inactivity.
   
Ice 20 minutes every 2-4 hours while the patient is

awake for first 48-72 hours

Compress Bandage, tape or brace for majority of acute period
Elevate affected limb for 1-2 hour periods during the day a

pillow under an injured limb at night

Table 2 Guidelines for return to sport after injury

• acute signs and symptoms have passed

 
• full functional use of all joints, adequate strength and proprioception to perform tasks

• normal mechanics of movement

• successful performance of sport specific activities at or above pre-injury level should

be documented